Healthcare Provider Details

I. General information

NPI: 1174703797
Provider Name (Legal Business Name): SHANNA LEE BHASIN PT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/12/2007
Last Update Date: 11/12/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5 BON AIR RD SUITE A-105
LARKSPUR CA
94939-1143
US

IV. Provider business mailing address

5 BON AIR RD SUITE A-105
LARKSPUR CA
94939-1143
US

V. Phone/Fax

Practice location:
  • Phone: 415-927-2007
  • Fax: 415-927-7272
Mailing address:
  • Phone: 415-927-2007
  • Fax: 415-927-7272

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPT32082
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: