Provider Demographics
NPI:1285749580
Name:LAIRD, SHANNON D (PT)
Entity type:Individual
Prefix:
First Name:SHANNON
Middle Name:D
Last Name:LAIRD
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:212 CARTER DR
Mailing Address - Street 2:SUITE C
Mailing Address - City:MIDDLETOWN
Mailing Address - State:DE
Mailing Address - Zip Code:19709-5837
Mailing Address - Country:US
Mailing Address - Phone:302-378-7174
Mailing Address - Fax:302-378-7157
Practice Address - Street 1:212 CARTER DR
Practice Address - Street 2:SUITE C
Practice Address - City:MIDDLETOWN
Practice Address - State:DE
Practice Address - Zip Code:19709-5837
Practice Address - Country:US
Practice Address - Phone:302-378-7174
Practice Address - Fax:302-378-7157
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-20
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DEJ1-0001678225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
DE1000030585Medicaid
DE1000030585Medicaid