Provider Demographics
NPI:1245629567
Name:SOLOMON, SHANNON (LMT)
Entity type:Individual
Prefix:
First Name:SHANNON
Middle Name:
Last Name:SOLOMON
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1063 YALE CIR
Mailing Address - Street 2:
Mailing Address - City:BOULDER
Mailing Address - State:CO
Mailing Address - Zip Code:80305-6406
Mailing Address - Country:US
Mailing Address - Phone:303-709-2231
Mailing Address - Fax:
Practice Address - Street 1:1800 30TH ST
Practice Address - Street 2:SUITE 210-J
Practice Address - City:BOULDER
Practice Address - State:CO
Practice Address - Zip Code:80301-1088
Practice Address - Country:US
Practice Address - Phone:303-709-2231
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-01-12
Last Update Date:2015-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO0015363225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO0015363OtherMASSAGE THERAPY