Provider Demographics
NPI:1154638302
Name:BLY, SHAWNA
Entity Type:Individual
Prefix:
First Name:SHAWNA
Middle Name:
Last Name:BLY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:945 22ND ST
Mailing Address - Street 2:
Mailing Address - City:SAN LEON
Mailing Address - State:TX
Mailing Address - Zip Code:77539
Mailing Address - Country:US
Mailing Address - Phone:832-385-0338
Mailing Address - Fax:
Practice Address - Street 1:945 22ND ST
Practice Address - Street 2:
Practice Address - City:SAN LEON
Practice Address - State:TX
Practice Address - Zip Code:77539-7211
Practice Address - Country:US
Practice Address - Phone:832-385-0338
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-09-09
Last Update Date:2024-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX2075727225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX2075727OtherSTATE LICENSE