Provider Demographics
NPI:1740658541
Name:LEVENSON, SHANE
Entity type:Individual
Prefix:
First Name:SHANE
Middle Name:
Last Name:LEVENSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2603 LOWER GAINESVILLE RD
Mailing Address - Street 2:
Mailing Address - City:STENNIS SPACE CENTER
Mailing Address - State:MS
Mailing Address - Zip Code:39529-7099
Mailing Address - Country:US
Mailing Address - Phone:228-813-4000
Mailing Address - Fax:
Practice Address - Street 1:2603 LOWER GAINESVILLE RD
Practice Address - Street 2:
Practice Address - City:STENNIS SPACE CENTER
Practice Address - State:MS
Practice Address - Zip Code:39529-7099
Practice Address - Country:US
Practice Address - Phone:228-813-4000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-09-10
Last Update Date:2015-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSAT04522255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer