Provider Demographics
NPI:1003228263
Name:GENGENBACHER, SHANNON PATRICIA (PT, DPT)
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:PATRICIA
Last Name:GENGENBACHER
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 1:3614 LANDINGS RD
Mailing Address - Street 2:
Mailing Address - City:JOLIET
Mailing Address - State:IL
Mailing Address - Zip Code:60431-1597
Mailing Address - Country:US
Mailing Address - Phone:610-457-0052
Mailing Address - Fax:
Practice Address - Street 1:14731 S VAN DYKE RD
Practice Address - Street 2:
Practice Address - City:PLAINFIELD
Practice Address - State:IL
Practice Address - Zip Code:60544-3185
Practice Address - Country:US
Practice Address - Phone:815-267-3196
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-05-22
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL070019069225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist