=====================================================
General NPI Number Information
=====================================================
NPI Number | 1306443999
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | SHANNON ELIZABETH BRICKLEY LMT
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/06/2020
-----------------------------------------------------
Last Update Date | 10/06/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3951 W PARMER LN STE 300
-----------------------------------------------------
City | AUSTIN
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 78727-4126
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 512-339-2663
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1005 LONESOME LILLY WAY
-----------------------------------------------------
City | PFLUGERVILLE
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 78660-5455
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 512-660-2990
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225700000X
-----------------------------------------------------
Taxonomy Name | Massage Therapist
-----------------------------------------------------
License Number | 114411
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------