Provider Demographics
NPI:1669771002
Name:SWEENEY, SHANNON KIM (LMT)
Entity type:Individual
Prefix:MISS
First Name:SHANNON
Middle Name:KIM
Last Name:SWEENEY
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 1:3380 MARIGOLD DR
Mailing Address - Street 2:
Mailing Address - City:PRESCOTT
Mailing Address - State:AZ
Mailing Address - Zip Code:86305-3714
Mailing Address - Country:US
Mailing Address - Phone:928-308-1053
Mailing Address - Fax:928-778-5665
Practice Address - Street 1:3111 CLEARWATER DR
Practice Address - Street 2:
Practice Address - City:PRESCOTT
Practice Address - State:AZ
Practice Address - Zip Code:86305-7186
Practice Address - Country:US
Practice Address - Phone:928-308-1053
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-03-24
Last Update Date:2011-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZMT-04194P225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist