Provider Demographics
NPI:1083945216
Name:BROCKWELL, SHANNON E (PTA)
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:E
Last Name:BROCKWELL
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:401 W MARTINTOWN RD
Mailing Address - Street 2:SUITE 169
Mailing Address - City:NORTH AUGUSTA
Mailing Address - State:SC
Mailing Address - Zip Code:29841-3194
Mailing Address - Country:US
Mailing Address - Phone:803-441-0025
Mailing Address - Fax:
Practice Address - Street 1:401 W MARTINTOWN RD
Practice Address - Street 2:SUITE 169
Practice Address - City:NORTH AUGUSTA
Practice Address - State:SC
Practice Address - Zip Code:29841-3194
Practice Address - Country:US
Practice Address - Phone:803-441-0025
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-01-28
Last Update Date:2010-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPTA 002671225200000X
SCPTA 2460225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA116819OtherMEDICARE REHABILITATION AGENCY CERTIFICATION NUMBER
SC426619OtherMEDICARE REHABILITATION AGENCY CERTIFICATION NUMBER