Provider Demographics
NPI:1831130681
Name:GAVIN, SHANNON C (PT)
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:C
Last Name:GAVIN
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:6822 OAK CLUSTER DR
Mailing Address - Street 2:
Mailing Address - City:GREENWELL SPRINGS
Mailing Address - State:LA
Mailing Address - Zip Code:70739-4139
Mailing Address - Country:US
Mailing Address - Phone:225-683-1111
Mailing Address - Fax:225-683-1177
Practice Address - Street 1:9609 PLANK RD
Practice Address - Street 2:SUITE P
Practice Address - City:CLINTON
Practice Address - State:LA
Practice Address - Zip Code:70722-3702
Practice Address - Country:US
Practice Address - Phone:225-683-1111
Practice Address - Fax:225-683-1177
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-06-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
LA03685225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist