Provider Demographics
NPI:1194121319
Name:COUGHLIN, SHANNON E (PT, DPT)
Entity type:Individual
Prefix:DR
First Name:SHANNON
Middle Name:E
Last Name:COUGHLIN
Suffix:
Gender:F
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12023 GOSHEN AVE APT 1
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90049-6316
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:12023 GOSHEN AVE APT 1
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90049-6316
Practice Address - Country:US
Practice Address - Phone:401-573-6784
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-11-16
Last Update Date:2014-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA415672251P0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251P0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistPediatrics