Provider Demographics
NPI:1073669826
Name:SHANLEY, SUSAN (RPT)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:
Last Name:SHANLEY
Suffix:
Gender:F
Credentials:RPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:349 OLD JAIL LANE
Mailing Address - Street 2:
Mailing Address - City:BARNSTABLE
Mailing Address - State:MA
Mailing Address - Zip Code:02630
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:61 QUAKER MEETING HOUSE RD
Practice Address - Street 2:
Practice Address - City:SANDWICH
Practice Address - State:MA
Practice Address - Zip Code:02563-2400
Practice Address - Country:US
Practice Address - Phone:508-477-8550
Practice Address - Fax:508-477-6989
Is Sole Proprietor?:No
Enumeration Date:2007-01-26
Last Update Date:2008-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA4318225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAY68081Medicare PIN
MAY6808101Medicare PIN