Provider Demographics
NPI:1619407459
Name:O'BRIEN, SHANNON (PT, DPT)
Entity type:Individual
Prefix:
First Name:SHANNON
Middle Name:
Last Name:O'BRIEN
Suffix:
Gender:F
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:26081 MERIT CIR STE 107
Mailing Address - Street 2:
Mailing Address - City:LAGUNA HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:92653-7017
Mailing Address - Country:US
Mailing Address - Phone:949-367-0310
Mailing Address - Fax:
Practice Address - Street 1:26081 MERIT CIR STE 107
Practice Address - Street 2:
Practice Address - City:LAGUNA HILLS
Practice Address - State:CA
Practice Address - Zip Code:92653-7017
Practice Address - Country:US
Practice Address - Phone:949-367-0310
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-06-14
Last Update Date:2017-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA2930482081P0010X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2081P0010XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationPediatric Rehabilitation Medicine