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 1:137 SANDY BOTTOM RD
Mailing Address - Street 2:
Mailing Address - City:COVENTRY
Mailing Address - State:RI
Mailing Address - Zip Code:02816-5865
Mailing Address - Country:US
Mailing Address - Phone:603-315-0525
Mailing Address - Fax:
Practice Address - Street 1:137 SANDY BOTTOM RD
Practice Address - Street 2:
Practice Address - City:COVENTRY
Practice Address - State:RI
Practice Address - Zip Code:02816-5865
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:2013-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIMT01810225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
RIMT01810OtherLICENSE