Provider Demographics
NPI:1922405851
Name:SHAUGHNESSY, KELLEY (LMT)
Entity Type:Individual
Prefix:
First Name:KELLEY
Middle Name:
Last Name:SHAUGHNESSY
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1397 S CANFIELD NILES RD
Mailing Address - Street 2:UNIT 1
Mailing Address - City:AUSTINTOWN
Mailing Address - State:OH
Mailing Address - Zip Code:44515-4084
Mailing Address - Country:US
Mailing Address - Phone:330-953-0129
Mailing Address - Fax:330-953-0650
Practice Address - Street 1:7620 SOUTHERN BLVD
Practice Address - Street 2:STE 3
Practice Address - City:BOARDMAN
Practice Address - State:OH
Practice Address - Zip Code:44512-5667
Practice Address - Country:US
Practice Address - Phone:330-965-9330
Practice Address - Fax:330-965-9308
Is Sole Proprietor?:No
Enumeration Date:2014-11-20
Last Update Date:2016-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH33.013613-S225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH33.013613-SOtherLMT