Provider Demographics
NPI:1659831030
Name:SAFUTO, SHANNAN (LMT)
Entity Type:Individual
Prefix:MRS
First Name:SHANNAN
Middle Name:
Last Name:SAFUTO
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:325 N 4TH ST
Mailing Address - Street 2:
Mailing Address - City:LINDENHURST
Mailing Address - State:NY
Mailing Address - Zip Code:11757-3329
Mailing Address - Country:US
Mailing Address - Phone:631-317-0311
Mailing Address - Fax:
Practice Address - Street 1:325 N 4TH ST
Practice Address - Street 2:
Practice Address - City:LINDENHURST
Practice Address - State:NY
Practice Address - Zip Code:11757-3329
Practice Address - Country:US
Practice Address - Phone:631-317-0311
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-03-22
Last Update Date:2019-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0220531225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist