Provider Demographics
NPI:1053630418
Name:DELUCA, SHANNON DAWN (PT)
Entity Type:Individual
Prefix:MRS
First Name:SHANNON
Middle Name:DAWN
Last Name:DELUCA
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 1:1010 ROUTE 112
Mailing Address - Street 2:SUITE 200
Mailing Address - City:PORT JEFFERSON STATION
Mailing Address - State:NY
Mailing Address - Zip Code:11776-3387
Mailing Address - Country:US
Mailing Address - Phone:631-476-4880
Mailing Address - Fax:631-476-4887
Practice Address - Street 1:1010 ROUTE 112
Practice Address - Street 2:SUITE 200
Practice Address - City:PORT JEFFERSON STATION
Practice Address - State:NY
Practice Address - Zip Code:11776-3387
Practice Address - Country:US
Practice Address - Phone:631-476-4880
Practice Address - Fax:631-476-4887
Is Sole Proprietor?:No
Enumeration Date:2010-05-25
Last Update Date:2016-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY028273174400000X, 225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No174400000XOther Service ProvidersSpecialist