Provider Demographics
NPI:1265971196
Name:MCLAREN, SHANNON (LMT)
Entity type:Individual
Prefix:
First Name:SHANNON
Middle Name:
Last Name:MCLAREN
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1135 MIRA MAR AVE
Mailing Address - Street 2:
Mailing Address - City:MEDFORD
Mailing Address - State:OR
Mailing Address - Zip Code:97504-8576
Mailing Address - Country:US
Mailing Address - Phone:541-630-1880
Mailing Address - Fax:
Practice Address - Street 1:1135 MIRA MAR AVE
Practice Address - Street 2:
Practice Address - City:MEDFORD
Practice Address - State:OR
Practice Address - Zip Code:97504-8576
Practice Address - Country:US
Practice Address - Phone:541-630-1880
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-02-12
Last Update Date:2017-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR17305225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist