Provider Demographics
NPI:1881654465
Name:SHANNON, MICHAEL GLEN (PHYSICAL THERAPIST)
Entity Type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:GLEN
Last Name:SHANNON
Suffix:
Gender:M
Credentials:PHYSICAL THERAPIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Mailing Address - Street 1:4358 FERGUSON DR
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45245-1680
Mailing Address - Country:US
Mailing Address - Phone:513-943-5322
Mailing Address - Fax:513-943-0725
Practice Address - Street 1:4358 FERGUSON DR
Practice Address - Street 2:
Practice Address - City:CINCINNATI
Practice Address - State:OH
Practice Address - Zip Code:45245-1680
Practice Address - Country:US
Practice Address - Phone:513-943-5322
Practice Address - Fax:513-943-0725
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-03-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH6392225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist