Provider Demographics
NPI:1962630061
Name:HEALY, SHANNON LOGAN (PT)
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:LOGAN
Last Name:HEALY
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1033 12TH ST
Mailing Address - Street 2:102
Mailing Address - City:SANTA MONICA
Mailing Address - State:CA
Mailing Address - Zip Code:90403
Mailing Address - Country:US
Mailing Address - Phone:310-650-3854
Mailing Address - Fax:
Practice Address - Street 1:1033 12TH ST
Practice Address - Street 2:102
Practice Address - City:SANTA MONICA
Practice Address - State:CA
Practice Address - Zip Code:90403
Practice Address - Country:US
Practice Address - Phone:310-650-3854
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-06-26
Last Update Date:2010-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT35550225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPT35550OtherCA LICENCE