Provider Demographics
NPI:1174006209
Name:VICKERY, SHAUN (PT, MPT)
Entity Type:Individual
Prefix:
First Name:SHAUN
Middle Name:
Last Name:VICKERY
Suffix:
Gender:M
Credentials:PT, MPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:106 GENEVIEVE DR
Mailing Address - Street 2:
Mailing Address - City:MADISONVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:42431-5806
Mailing Address - Country:US
Mailing Address - Phone:270-836-6559
Mailing Address - Fax:
Practice Address - Street 1:425 ISLAND FORD ROAD
Practice Address - Street 2:
Practice Address - City:MADISONVILLE
Practice Address - State:KY
Practice Address - Zip Code:42431
Practice Address - Country:US
Practice Address - Phone:270-825-0166
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-09-14
Last Update Date:2018-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY004425225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist