Provider Demographics
NPI:1912755018
Name:CLARK, SHANNON T (LMT)
Entity type:Individual
Prefix:
First Name:SHANNON
Middle Name:T
Last Name:CLARK
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8500 N BEDFORD RD
Mailing Address - Street 2:
Mailing Address - City:MACEDONIA
Mailing Address - State:OH
Mailing Address - Zip Code:44056-1941
Mailing Address - Country:US
Mailing Address - Phone:330-468-1199
Mailing Address - Fax:
Practice Address - Street 1:8500 N BEDFORD RD
Practice Address - Street 2:
Practice Address - City:MACEDONIA
Practice Address - State:OH
Practice Address - Zip Code:44056-1941
Practice Address - Country:US
Practice Address - Phone:330-468-1199
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-05-13
Last Update Date:2024-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH33.025918225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist