Provider Demographics
NPI:1447657226
Name:GORMAN, SHANNON (PT, DPT)
Entity type:Individual
Prefix:
First Name:SHANNON
Middle Name:
Last Name:GORMAN
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 1:227 N EL CAMINO REAL
Mailing Address - Street 2:STE 100
Mailing Address - City:ENCINITAS
Mailing Address - State:CA
Mailing Address - Zip Code:92024-5821
Mailing Address - Country:US
Mailing Address - Phone:760-205-1500
Mailing Address - Fax:
Practice Address - Street 1:227 N EL CAMINO REAL
Practice Address - Street 2:SUITE 103
Practice Address - City:ENCINITAS
Practice Address - State:CA
Practice Address - Zip Code:92024-2807
Practice Address - Country:US
Practice Address - Phone:760-230-2316
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-11-22
Last Update Date:2016-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA41936225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist