Provider Demographics
NPI:1134094022
Name:MARTIN, SHANNON E (LMT, CLT)
Entity type:Individual
Prefix:MRS
First Name:SHANNON
Middle Name:E
Last Name:MARTIN
Suffix:
Gender:F
Credentials:LMT, CLT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:60 RIVERSIDE DR APT 1F
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10024-6164
Mailing Address - Country:US
Mailing Address - Phone:773-673-0596
Mailing Address - Fax:
Practice Address - Street 1:279 CENTRAL PARK W
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10024-3080
Practice Address - Country:US
Practice Address - Phone:212-877-1711
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-10-09
Last Update Date:2025-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY03353701225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Multi-Specialty