Provider Demographics
NPI:1275619009
Name:GOODHUE, SHANNON E (PT)
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:E
Last Name:GOODHUE
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:SHANNON
Other - Middle Name:
Other - Last Name:CONLON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT
Mailing Address - Street 1:8087 WASHINGTON VILLAGE DR STE 101
Mailing Address - Street 2:
Mailing Address - City:CENTERVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:45458-1873
Mailing Address - Country:US
Mailing Address - Phone:937-938-8380
Mailing Address - Fax:937-938-8392
Practice Address - Street 1:8087 WASHINGTON VILLAGE DR STE 101
Practice Address - Street 2:
Practice Address - City:CENTERVILLE
Practice Address - State:OH
Practice Address - Zip Code:45458-1873
Practice Address - Country:US
Practice Address - Phone:937-938-8380
Practice Address - Fax:937-938-8392
Is Sole Proprietor?:No
Enumeration Date:2006-10-27
Last Update Date:2010-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHPT011345225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0108341Medicaid
OH382617193-30OtherBWC
OH000000190966OtherBC/BS
OH000000190966OtherBC/BS
OH382617193-30OtherBWC