Provider Demographics
NPI:1962430264
Name:SMITH, SHANNON M (MPT)
Entity type:Individual
Prefix:
First Name:SHANNON
Middle Name:M
Last Name:SMITH
Suffix:
Gender:F
Credentials:MPT
Other - Prefix:
Other - First Name:SHANNON
Other - Middle Name:M
Other - Last Name:GARDAM
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MPT
Mailing Address - Street 1:16844 SAINT CLAIR AVE
Mailing Address - Street 2:
Mailing Address - City:EAST LIVERPOOL
Mailing Address - State:OH
Mailing Address - Zip Code:43920-4277
Mailing Address - Country:US
Mailing Address - Phone:330-386-6500
Mailing Address - Fax:330-386-1277
Practice Address - Street 1:16844 SAINT CLAIR AVE
Practice Address - Street 2:
Practice Address - City:EAST LIVERPOOL
Practice Address - State:OH
Practice Address - Zip Code:43920-4277
Practice Address - Country:US
Practice Address - Phone:330-386-6500
Practice Address - Fax:330-386-1277
Is Sole Proprietor?:No
Enumeration Date:2006-06-28
Last Update Date:2008-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHPT10951225100000X
PAPT016707225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist