Healthcare Provider Details

I. General information

NPI: 1992220610
Provider Name (Legal Business Name): SHANNON SMITH DPT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/03/2017
Last Update Date: 08/03/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

185 HARRISON AVE
BOSTON MA
02111-1804
US

IV. Provider business mailing address

10 BEETHOVEN ST APT 2
ROXBURY MA
02119-3109
US

V. Phone/Fax

Practice location:
  • Phone: 617-636-5632
  • Fax:
Mailing address:
  • Phone: 774-437-1026
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: