Provider Demographics
NPI:1992299358
Name:LONG, SHANNON OLIVIA (PT, DPT)
Entity type:Individual
Prefix:
First Name:SHANNON
Middle Name:OLIVIA
Last Name:LONG
Suffix:
Gender:F
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10780 SANTA MONICA BLVD STE 405
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90025-7655
Mailing Address - Country:US
Mailing Address - Phone:310-234-0300
Mailing Address - Fax:310-234-0304
Practice Address - Street 1:10780 SANTA MONICA BLVD STE 405
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90025-7655
Practice Address - Country:US
Practice Address - Phone:310-234-0300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-06-19
Last Update Date:2018-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA291794225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist