Provider Demographics
NPI:1104324250
Name:BALL, SHANNA MARIE (CMT)
Entity type:Individual
Prefix:MS
First Name:SHANNA
Middle Name:MARIE
Last Name:BALL
Suffix:
Gender:F
Credentials:CMT
Other - Prefix:
Other - First Name:LIFESTYLE:
Other - Middle Name:
Other - Last Name:WELLNESS
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:D/B/A NAME
Mailing Address - Street 1:12548 OAK KNOLL RD APT C21
Mailing Address - Street 2:
Mailing Address - City:POWAY
Mailing Address - State:CA
Mailing Address - Zip Code:92064-5494
Mailing Address - Country:US
Mailing Address - Phone:928-216-0473
Mailing Address - Fax:
Practice Address - Street 1:4110 SORRENTO VALLEY BLVD
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92121-1429
Practice Address - Country:US
Practice Address - Phone:858-246-9730
Practice Address - Fax:858-246-9710
Is Sole Proprietor?:Yes
Enumeration Date:2018-01-24
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA71862225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist