Basic Information
| Provider Information | |||||||||
| NPI: | 1285749580 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | LAIRD | ||||||||
| FirstName: | SHANNON | ||||||||
| MiddleName: | D | ||||||||
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| Credential: | PT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 212 CARTER DR | ||||||||
| Address2: | SUITE C | ||||||||
| City: | MIDDLETOWN | ||||||||
| State: | DE | ||||||||
| PostalCode: | 197095837 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3023787174 | ||||||||
| FaxNumber: | 3023787157 | ||||||||
| Practice Location | |||||||||
| Address1: | 212 CARTER DR | ||||||||
| Address2: | SUITE C | ||||||||
| City: | MIDDLETOWN | ||||||||
| State: | DE | ||||||||
| PostalCode: | 197095837 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3023787174 | ||||||||
| FaxNumber: | 3023787157 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/20/2006 | ||||||||
| LastUpdateDate: | 07/09/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | J1-0001678 | DE | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | 1000030585 | 05 | DE | MEDICAID |