Provider Demographics
NPI:1538745534
Name:TETTEH, SHANNON L
Entity type:Individual
Prefix:
First Name:SHANNON
Middle Name:L
Last Name:TETTEH
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 1:1507 E 53RD ST # 297
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60615-4573
Mailing Address - Country:US
Mailing Address - Phone:312-927-0606
Mailing Address - Fax:
Practice Address - Street 1:1509 E MARQUETTE RD APT 1W
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60637-6470
Practice Address - Country:US
Practice Address - Phone:312-927-0606
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-03-20
Last Update Date:2021-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL227012219225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist