Provider Demographics
NPI:1053681593
Name:SHANNON, CORINNE (PT)
Entity Type:Individual
Prefix:
First Name:CORINNE
Middle Name:
Last Name:SHANNON
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 1:500 N KINGSBURY ST
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60654-5721
Mailing Address - Country:US
Mailing Address - Phone:312-527-5801
Mailing Address - Fax:312-644-4567
Practice Address - Street 1:500 N KINGSBURY ST
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60654-5721
Practice Address - Country:US
Practice Address - Phone:312-527-5801
Practice Address - Fax:312-644-4567
Is Sole Proprietor?:No
Enumeration Date:2011-12-30
Last Update Date:2011-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL070-015323225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist