Provider Demographics
NPI:1245239078
Name:MIDDLETON, SHANNON BLAKE (BS, MPT, DPT)
Entity Type:Individual
Prefix:MRS
First Name:SHANNON
Middle Name:BLAKE
Last Name:MIDDLETON
Suffix:
Gender:F
Credentials:BS, MPT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1325 E KEMPER RD
Mailing Address - Street 2:STE 100
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45246-3921
Mailing Address - Country:US
Mailing Address - Phone:513-823-4247
Mailing Address - Fax:
Practice Address - Street 1:1325 E KEMPER RD
Practice Address - Street 2:STE 100
Practice Address - City:CINCINNATI
Practice Address - State:OH
Practice Address - Zip Code:45246-3921
Practice Address - Country:US
Practice Address - Phone:513-823-4247
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-07-14
Last Update Date:2016-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHPT10466225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHP00395152OtherMEDICARE RAILROAD
OH2565988Medicaid
OH2565988Medicaid