Provider Demographics
NPI:1306484399
Name:WELCH, SHANNON
Entity type:Individual
Prefix:
First Name:SHANNON
Middle Name:
Last Name:WELCH
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7266 PORTAGE ST NW
Mailing Address - Street 2:
Mailing Address - City:MASSILLON
Mailing Address - State:OH
Mailing Address - Zip Code:44646-7986
Mailing Address - Country:US
Mailing Address - Phone:330-818-1212
Mailing Address - Fax:
Practice Address - Street 1:7266 PORTAGE ST NW
Practice Address - Street 2:
Practice Address - City:MASSILLON
Practice Address - State:OH
Practice Address - Zip Code:44646-7986
Practice Address - Country:US
Practice Address - Phone:330-818-1212
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-12-20
Last Update Date:2019-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH33011711T-Z225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
33011711T-ZOtherLMT