Provider Demographics
NPI:1841352325
Name:SIMMONS, SHANNON LEE (PT)
Entity type:Individual
Prefix:
First Name:SHANNON
Middle Name:LEE
Last Name:SIMMONS
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 1:2953 BLOOM RD
Mailing Address - Street 2:
Mailing Address - City:FINKSBURG
Mailing Address - State:MD
Mailing Address - Zip Code:21048
Mailing Address - Country:US
Mailing Address - Phone:443-812-0604
Mailing Address - Fax:
Practice Address - Street 1:2953 BLOOM RD
Practice Address - Street 2:
Practice Address - City:FINKSBURG
Practice Address - State:MD
Practice Address - Zip Code:21048
Practice Address - Country:US
Practice Address - Phone:443-812-0604
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-14
Last Update Date:2013-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD19867225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
S984J500Medicare ID - Type Unspecified