Provider Demographics
NPI:1164414454
Name:KIRSCH, SHANNON R (PT)
Entity Type:Individual
Prefix:MRS
First Name:SHANNON
Middle Name:R
Last Name:KIRSCH
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 1:2001 7TH ST
Mailing Address - Street 2:
Mailing Address - City:RAPID CITY
Mailing Address - State:SD
Mailing Address - Zip Code:57701-4661
Mailing Address - Country:US
Mailing Address - Phone:605-716-6474
Mailing Address - Fax:605-716-6484
Practice Address - Street 1:2001 7TH ST
Practice Address - Street 2:
Practice Address - City:RAPID CITY
Practice Address - State:SD
Practice Address - Zip Code:57701-4661
Practice Address - Country:US
Practice Address - Phone:605-716-6474
Practice Address - Fax:605-716-6484
Is Sole Proprietor?:No
Enumeration Date:2005-08-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD0512225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
SD5831562Medicaid
41220Medicare ID - Type Unspecified