Provider Demographics
NPI:1841714292
Name:GOINS-BLAIR, SHANNON (CLT-LANA, LMT, MA)
Entity type:Individual
Prefix:
First Name:SHANNON
Middle Name:
Last Name:GOINS-BLAIR
Suffix:
Gender:
Credentials:CLT-LANA, LMT, MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20 CAMINO YRISARRI
Mailing Address - Street 2:
Mailing Address - City:TIJERAS
Mailing Address - State:NM
Mailing Address - Zip Code:87059-6300
Mailing Address - Country:US
Mailing Address - Phone:505-269-5338
Mailing Address - Fax:
Practice Address - Street 1:5310 HOMESTEAD RD NE STE 202A
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87110-1524
Practice Address - Country:US
Practice Address - Phone:505-554-1855
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-07-27
Last Update Date:2025-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM8941225700000X, 225700000X
CLT246Z00000X, 246Z00000X
FUNCTIONALMEDICINE171400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
No246Z00000XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, Other
Yes171400000XOther Service ProvidersHealth & Wellness Coach
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM8941OtherSTATE OF NEW MEXICO MASSAGE THERAPY BOARD
LANAOtherLYMPHOLOGY ASSOCIATION OF NORTH AMERICA
CLTOtherKLOSE TRAINING - CERTIFIED LYMPHEDEMA THERAPIST
FMHCOtherFUNCTIONAL MEDICINE HEALTH COACH