Provider Demographics
NPI:1811354053
Name:WEBB, SHANNON (PTA)
Entity type:Individual
Prefix:
First Name:SHANNON
Middle Name:
Last Name:WEBB
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17 FORAN RD
Mailing Address - Street 2:APT 15
Mailing Address - City:MILFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06460-7756
Mailing Address - Country:US
Mailing Address - Phone:860-417-9459
Mailing Address - Fax:
Practice Address - Street 1:1 BRADLEY RD
Practice Address - Street 2:STE 801
Practice Address - City:WOODBRIDGE
Practice Address - State:CT
Practice Address - Zip Code:06525-2285
Practice Address - Country:US
Practice Address - Phone:860-417-9459
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-01-19
Last Update Date:2017-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT16832081S0010X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2081S0010XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationSports Medicine