Provider Demographics
NPI:1033583091
Name:ORTMAN, SHANNON (PT)
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:
Last Name:ORTMAN
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:555 N NEW BALLAS RD
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63141-6825
Mailing Address - Country:US
Mailing Address - Phone:314-432-7100
Mailing Address - Fax:314-432-7259
Practice Address - Street 1:555 N NEW BALLAS RD
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63141-6825
Practice Address - Country:US
Practice Address - Phone:314-432-7100
Practice Address - Fax:314-432-7259
Is Sole Proprietor?:No
Enumeration Date:2015-11-13
Last Update Date:2015-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2015039542225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist