Provider Demographics
NPI:1790214617
Name:NEVIN, SHANNON MARIE (LMT)
Entity Type:Individual
Prefix:MRS
First Name:SHANNON
Middle Name:MARIE
Last Name:NEVIN
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 1:24304 NYS RTE 37
Mailing Address - Street 2:
Mailing Address - City:WATERTOWN
Mailing Address - State:NY
Mailing Address - Zip Code:13601-5870
Mailing Address - Country:US
Mailing Address - Phone:315-785-9588
Mailing Address - Fax:
Practice Address - Street 1:24304 NYS RTE 37
Practice Address - Street 2:
Practice Address - City:WATERTOWN
Practice Address - State:NY
Practice Address - Zip Code:13601-5870
Practice Address - Country:US
Practice Address - Phone:315-785-9588
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-06-05
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY015815225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist