Provider Demographics
NPI:1235569625
Name:MCDANIEL, SHANNON KAY (PT)
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:KAY
Last Name:MCDANIEL
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:PO BOX 7157
Mailing Address - Street 2:
Mailing Address - City:TYLER
Mailing Address - State:TX
Mailing Address - Zip Code:75711-7157
Mailing Address - Country:US
Mailing Address - Phone:903-595-6126
Mailing Address - Fax:903-595-2298
Practice Address - Street 1:3400 S BROADWAY AVE
Practice Address - Street 2:SUITE 205
Practice Address - City:TYLER
Practice Address - State:TX
Practice Address - Zip Code:75701-8728
Practice Address - Country:US
Practice Address - Phone:903-595-6126
Practice Address - Fax:903-595-2298
Is Sole Proprietor?:No
Enumeration Date:2013-11-21
Last Update Date:2013-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1106284225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1106284OtherPHYSICAL THERAPY LICENSE NUMBER