Provider Demographics
NPI:1831854108
Name:LOCKRIDGE, SHAWN (LMT)
Entity type:Individual
Prefix:
First Name:SHAWN
Middle Name:
Last Name:LOCKRIDGE
Suffix:
Gender:M
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2401 QUARRYSTONE LN
Mailing Address - Street 2:
Mailing Address - City:MIDDLE ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:11953-1479
Mailing Address - Country:US
Mailing Address - Phone:631-522-6975
Mailing Address - Fax:
Practice Address - Street 1:121 PULASKI RD
Practice Address - Street 2:
Practice Address - City:KINGS PARK
Practice Address - State:NY
Practice Address - Zip Code:11754-2539
Practice Address - Country:US
Practice Address - Phone:631-455-9347
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-11-02
Last Update Date:2022-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY019168225700000X
225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Single Specialty