Provider Demographics
NPI:1588323877
Name:SHODD, DOUGLAS MARTIN SR (LMT)
Entity type:Individual
Prefix:
First Name:DOUGLAS
Middle Name:MARTIN
Last Name:SHODD
Suffix:SR
Gender:M
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:8120 SOUTHERN BLVD APT 1
Mailing Address - Street 2:
Mailing Address - City:BOARDMAN
Mailing Address - State:OH
Mailing Address - Zip Code:44512-6309
Mailing Address - Country:US
Mailing Address - Phone:330-652-4222
Mailing Address - Fax:330-652-0574
Practice Address - Street 1:2400 NILES CORTLAND RD SE
Practice Address - Street 2:
Practice Address - City:WARREN
Practice Address - State:OH
Practice Address - Zip Code:44484-3869
Practice Address - Country:US
Practice Address - Phone:330-652-4222
Practice Address - Fax:330-652-0574
Is Sole Proprietor?:Yes
Enumeration Date:2021-12-14
Last Update Date:2021-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH33.006135225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist