Provider Demographics
NPI:1134326341
Name:GILL, SHANNON E (PTA)
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:E
Last Name:GILL
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 1:8211 W 127TH AVE
Mailing Address - Street 2:
Mailing Address - City:CEDAR LAKE
Mailing Address - State:IN
Mailing Address - Zip Code:46303-8873
Mailing Address - Country:US
Mailing Address - Phone:219-374-7157
Mailing Address - Fax:
Practice Address - Street 1:6040 LUTE RD
Practice Address - Street 2:
Practice Address - City:PORTAGE
Practice Address - State:IN
Practice Address - Zip Code:46368-5008
Practice Address - Country:US
Practice Address - Phone:219-763-6858
Practice Address - Fax:219-763-4858
Is Sole Proprietor?:No
Enumeration Date:2007-06-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN06001802A225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant