Provider Demographics
NPI:1043451495
Name:LUBS, SHANNON (DPT)
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:
Last Name:LUBS
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:SHANNON
Other - Middle Name:
Other - Last Name:KRUGER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:600 OAKMONT LN STE 600C
Mailing Address - Street 2:
Mailing Address - City:WESTMONT
Mailing Address - State:IL
Mailing Address - Zip Code:60559-5548
Mailing Address - Country:US
Mailing Address - Phone:630-575-6200
Mailing Address - Fax:630-928-5080
Practice Address - Street 1:1600 E BELTLINE AVE NE
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49525
Practice Address - Country:US
Practice Address - Phone:616-818-0586
Practice Address - Fax:616-818-0587
Is Sole Proprietor?:No
Enumeration Date:2009-03-16
Last Update Date:2018-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL070-016974225100000X
MI5501017661225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist