Provider Demographics
NPI:1932216553
Name:WALTON, SHANNON MICHAEL (MSPT)
Entity Type:Individual
Prefix:MR
First Name:SHANNON
Middle Name:MICHAEL
Last Name:WALTON
Suffix:
Gender:M
Credentials:MSPT
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:88 PETERS POND DRIVE
Mailing Address - Street 2:
Mailing Address - City:DRACUT
Mailing Address - State:MA
Mailing Address - Zip Code:01826
Mailing Address - Country:US
Mailing Address - Phone:781-938-5387
Mailing Address - Fax:781-503-5039
Practice Address - Street 1:7 ALFRED ST
Practice Address - Street 2:SUITE 307
Practice Address - City:WOBURN
Practice Address - State:MA
Practice Address - Zip Code:01801-1976
Practice Address - Country:US
Practice Address - Phone:781-938-5387
Practice Address - Fax:781-503-5309
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA10570225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA64-00320OtherUNITED HEALTH
MA689253OtherTUFTS
MAY67408OtherBLUE CROSS BLUE SHIELD
MAAA43298OtherHARVARD PILGRIM
MAAA43298OtherHARVARD PILGRIM