Provider Demographics
NPI:1174249494
Name:SHANNON, MEGAN ELIZABETH
Entity type:Individual
Prefix:
First Name:MEGAN
Middle Name:ELIZABETH
Last Name:SHANNON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:790 REMINGTON BLVD
Mailing Address - Street 2:
Mailing Address - City:BOLINGBROOK
Mailing Address - State:IL
Mailing Address - Zip Code:60440-4909
Mailing Address - Country:US
Mailing Address - Phone:866-370-8206
Mailing Address - Fax:
Practice Address - Street 1:14 MCGRATH HWY UNIT 5
Practice Address - Street 2:
Practice Address - City:SOMERVILLE
Practice Address - State:MA
Practice Address - Zip Code:02143-4505
Practice Address - Country:US
Practice Address - Phone:617-284-9418
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-10-18
Last Update Date:2024-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MAPTL27681225100000X
NJ40QA02040400225100000X
CA303348225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist