Provider Demographics
NPI:1841659901
Name:SPRAGUE, SHANNON (LMT)
Entity type:Individual
Prefix:
First Name:SHANNON
Middle Name:
Last Name:SPRAGUE
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 1:1525 W HIGH ST
Mailing Address - Street 2:
Mailing Address - City:BRYAN
Mailing Address - State:OH
Mailing Address - Zip Code:43506-2599
Mailing Address - Country:US
Mailing Address - Phone:419-630-7290
Mailing Address - Fax:
Practice Address - Street 1:1525 W HIGH ST
Practice Address - Street 2:
Practice Address - City:BRYAN
Practice Address - State:OH
Practice Address - Zip Code:43506-2599
Practice Address - Country:US
Practice Address - Phone:419-630-7290
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-02-17
Last Update Date:2016-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH33021540225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist