Provider Demographics
NPI:1104069046
Name:JOHNSON, SHANNON (MSPT)
Entity type:Individual
Prefix:
First Name:SHANNON
Middle Name:
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:MSPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:545 W LOS ANGELES AVE
Mailing Address - Street 2:
Mailing Address - City:MOORPARK
Mailing Address - State:CA
Mailing Address - Zip Code:93021
Mailing Address - Country:US
Mailing Address - Phone:805-530-3838
Mailing Address - Fax:805-530-3832
Practice Address - Street 1:545 W LOS ANGELES AVE
Practice Address - Street 2:
Practice Address - City:MOORPARK
Practice Address - State:CA
Practice Address - Zip Code:93021
Practice Address - Country:US
Practice Address - Phone:805-530-3838
Practice Address - Fax:805-530-3832
Is Sole Proprietor?:No
Enumeration Date:2009-04-08
Last Update Date:2009-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA27137225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist