Provider Demographics
NPI:1861834301
Name:SEXTON POTTER, SHANNON LOUISE (LMT)
Entity type:Individual
Prefix:
First Name:SHANNON
Middle Name:LOUISE
Last Name:SEXTON POTTER
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:SHANNON
Other - Middle Name:LOUISE
Other - Last Name:SEXTON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LMT
Mailing Address - Street 1:31 CANTERBURY RD
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:CT
Mailing Address - Zip Code:06234-1901
Mailing Address - Country:US
Mailing Address - Phone:603-315-0525
Mailing Address - Fax:
Practice Address - Street 1:58 POMFRET ST
Practice Address - Street 2:
Practice Address - City:PUTNAM
Practice Address - State:CT
Practice Address - Zip Code:06260-1888
Practice Address - Country:US
Practice Address - Phone:603-315-0525
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-07-25
Last Update Date:2025-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT29011535225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT29011535OtherCT
RIMT01810OtherLICENSE