MEDICARE: SHANNON MARIE WILLOUGHBY LMT

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225700000X	Massage Therapist
2	225700000X	Massage Therapist	3485	SC

General Provider Information

NPI Number	:	1629318431
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SHANNON MARIE WILLOUGHBY LMT

Provider Business Mailing Address
First Line	:	6703 JEFFERSON PL APT B7
Second Line	:
City	:	MYRTLE BEACH
State	:	SC
Zip	:	29572-3708
Country	:	US
Telephone Number	:	843-232-6357
Fax Number	:

Provider Business Practice Location Address
First Line	:	211 HIGHWAY 17 N
Second Line	:
City	:	NORTH MYRTLE BEACH
State	:	SC
Zip	:	29582-8107
Country	:	US
Telephone Number	:	843-489-0788
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/15/2013
Last Update Date	:	05/12/2023

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Directions to “ SHANNON MARIE WILLOUGHBY LMT” Practice Location

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