Provider Demographics
NPI:1255634929
Name:ANDERSON III, SHANNON RICHARD (LMP)
Entity type:Individual
Prefix:MR
First Name:SHANNON
Middle Name:RICHARD
Last Name:ANDERSON III
Suffix:
Gender:M
Credentials:LMP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2107 MILL AVENUE
Mailing Address - Street 2:
Mailing Address - City:BELLINGHAM
Mailing Address - State:WA
Mailing Address - Zip Code:98225
Mailing Address - Country:US
Mailing Address - Phone:914-703-2189
Mailing Address - Fax:
Practice Address - Street 1:2107 MILL AVENUE
Practice Address - Street 2:
Practice Address - City:BELLINGHAM
Practice Address - State:WA
Practice Address - Zip Code:98225
Practice Address - Country:US
Practice Address - Phone:914-703-2189
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-12-17
Last Update Date:2011-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA60124184225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist