Provider Demographics
NPI:1962732701
Name:LOPEZ, SHANNON LEE (CMT)
Entity type:Individual
Prefix:
First Name:SHANNON
Middle Name:LEE
Last Name:LOPEZ
Suffix:
Gender:F
Credentials:CMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3189 W CALYPSO CT
Mailing Address - Street 2:
Mailing Address - City:CASTLE ROCK
Mailing Address - State:CO
Mailing Address - Zip Code:80109-2826
Mailing Address - Country:US
Mailing Address - Phone:720-296-9182
Mailing Address - Fax:
Practice Address - Street 1:3189 W CALYPSO CT
Practice Address - Street 2:
Practice Address - City:CASTLE ROCK
Practice Address - State:CO
Practice Address - Zip Code:80109-2826
Practice Address - Country:US
Practice Address - Phone:720-296-9182
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-12-29
Last Update Date:2009-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO3098225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Single Specialty