Provider Demographics
NPI:1699812800
Name:SHANNON, BARBARA
Entity Type:Individual
Prefix:
First Name:BARBARA
Middle Name:
Last Name:SHANNON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5757 WHITMORE LAKE RD
Mailing Address - Street 2:STE 900
Mailing Address - City:BRIGHTON
Mailing Address - State:MI
Mailing Address - Zip Code:48116-1962
Mailing Address - Country:US
Mailing Address - Phone:810-220-5793
Mailing Address - Fax:810-220-5805
Practice Address - Street 1:5757 WHITMORE LAKE RD
Practice Address - Street 2:STE 900
Practice Address - City:BRIGHTON
Practice Address - State:MI
Practice Address - Zip Code:48116-1962
Practice Address - Country:US
Practice Address - Phone:810-220-5793
Practice Address - Fax:810-220-5805
Is Sole Proprietor?:No
Enumeration Date:2007-01-30
Last Update Date:2017-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5501002932225100000X
MI741774225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0H25066OtherBCBS
MI741774OtherLICENSE NUMBER
MIMI6211017Medicare PIN
MI0H25066OtherBCBS
MIN82620014Medicare PIN