Provider Demographics
NPI:1285934620
Name:MORAN, SHANNON MARIE (PT)
Entity type:Individual
Prefix:MS
First Name:SHANNON
Middle Name:MARIE
Last Name:MORAN
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:SHANNON
Other - Middle Name:M
Other - Last Name:DAVIS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT
Mailing Address - Street 1:3100 SAMFORD AVE
Mailing Address - Street 2:
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71103-4239
Mailing Address - Country:US
Mailing Address - Phone:318-222-5704
Mailing Address - Fax:318-226-3316
Practice Address - Street 1:3100 SAMFORD AVE
Practice Address - Street 2:
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71103-4239
Practice Address - Country:US
Practice Address - Phone:318-222-5704
Practice Address - Fax:318-226-3316
Is Sole Proprietor?:No
Enumeration Date:2010-11-02
Last Update Date:2022-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA026102251P0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251P0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistPediatrics