Provider Demographics
NPI:1780832246
Name:MCEWEN, SHANNON DENISE (LMP)
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:DENISE
Last Name:MCEWEN
Suffix:
Gender:F
Credentials:LMP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2709 E MAIN
Mailing Address - Street 2:
Mailing Address - City:PUYALLUP
Mailing Address - State:WA
Mailing Address - Zip Code:98372-3165
Mailing Address - Country:US
Mailing Address - Phone:253-446-6558
Mailing Address - Fax:253-770-6495
Practice Address - Street 1:2709 E MAIN
Practice Address - Street 2:
Practice Address - City:PUYALLUP
Practice Address - State:WA
Practice Address - Zip Code:98372-3165
Practice Address - Country:US
Practice Address - Phone:253-446-6558
Practice Address - Fax:253-770-6495
Is Sole Proprietor?:Yes
Enumeration Date:2008-09-08
Last Update Date:2010-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA00022385225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist