Provider Demographics
NPI:1396344198
Name:BALLINGER, SHANNON (DPT)
Entity type:Individual
Prefix:
First Name:SHANNON
Middle Name:
Last Name:BALLINGER
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:SHANNON
Other - Middle Name:
Other - Last Name:HARRISON
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DPT
Mailing Address - Street 1:2991 S ELGIN HILL CT # 8
Mailing Address - Street 2:
Mailing Address - City:MILLCREEK
Mailing Address - State:UT
Mailing Address - Zip Code:84106-4549
Mailing Address - Country:US
Mailing Address - Phone:206-930-8971
Mailing Address - Fax:
Practice Address - Street 1:1470 400 W
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84115
Practice Address - Country:US
Practice Address - Phone:206-930-8971
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-10-22
Last Update Date:2020-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT11803306-2401261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy