Provider Demographics
NPI:1962895656
Name:LY, SHANNON
Entity type:Individual
Prefix:MRS
First Name:SHANNON
Middle Name:
Last Name:LY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:455 E COLUMBIA ST
Mailing Address - Street 2:SUITES 201 & 6
Mailing Address - City:LONG BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90806-1620
Mailing Address - Country:US
Mailing Address - Phone:562-933-0400
Mailing Address - Fax:562-933-0487
Practice Address - Street 1:455 E COLUMBIA ST
Practice Address - Street 2:SUITES 201 & 6
Practice Address - City:LONG BEACH
Practice Address - State:CA
Practice Address - Zip Code:90806-1620
Practice Address - Country:US
Practice Address - Phone:562-933-0400
Practice Address - Fax:562-933-0487
Is Sole Proprietor?:No
Enumeration Date:2015-03-05
Last Update Date:2015-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA821092225400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225400000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Practitioner