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General NPI Number Information
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NPI Number | 1518260405
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Entity Type | Organization
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Legal Business Name | SHANNON LOGAN HEALY PT
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Dates
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Enumeration Date | 12/15/2010
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Last Update Date | 12/15/2010
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Provider Practice Location Address
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Address Line | 1033 12TH STREET 102
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City | SANTA MONICA
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State | CA
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Zip | 90403
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Country | US
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Telephone | 310-650-3854
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Fax |
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Provider Business Mailing Address
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Address Line | 1033 12TH STREET 102
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City | SANTA MONICA
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State | CA
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Zip | 90403
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Country | US
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Telephone | 310-650-3854
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Fax |
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Authorized Official
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Title or Position | PHYSICAL THERAPIST/OWNER
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Name | MISS SHANNON LOGAN HEALY
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Credential | MPT
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Telephone | 310-650-3854
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 225100000X
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Taxonomy Name | Physical Therapist
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License Number | 35550
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License Number State | CA
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