Provider Demographics
NPI:1255903076
Name:FOXWORTH, SHANNEL (LMT)
Entity type:Individual
Prefix:
First Name:SHANNEL
Middle Name:
Last Name:FOXWORTH
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 1:133 W SEYMOUR ST FL 2
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19144-3639
Mailing Address - Country:US
Mailing Address - Phone:267-584-9536
Mailing Address - Fax:
Practice Address - Street 1:133 W SEYMOUR ST FL 2
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19144-3639
Practice Address - Country:US
Practice Address - Phone:267-584-9536
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-07-12
Last Update Date:2021-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMSG012643225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist