Healthcare Provider Details

I. General information

NPI: 1699419408
Provider Name (Legal Business Name): SHANNON PATTERSON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/27/2022
Last Update Date: 04/27/2022
Certification Date: 04/27/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

421 BIRCHTREE LN APT A
FORT WAYNE IN
46807-3659
US

IV. Provider business mailing address

421 BIRCHTREE LN APT A
FORT WAYNE IN
46807-3659
US

V. Phone/Fax

Practice location:
  • Phone: 412-719-5926
  • Fax:
Mailing address:
  • Phone: 412-719-5926
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225A00000X
TaxonomyMusic Therapist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: