Provider Demographics
NPI:1336506617
Name:SHUMATE BOURNE, JOSCELYN CELESTE (PT, DPT, CSCS)
Entity Type:Individual
Prefix:DR
First Name:JOSCELYN
Middle Name:CELESTE
Last Name:SHUMATE BOURNE
Suffix:
Gender:F
Credentials:PT, DPT, CSCS
Other - Prefix:DR
Other - First Name:JOSCELYN
Other - Middle Name:CELESTE
Other - Last Name:SHUMATE
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PT, DPT, CSCS
Mailing Address - Street 1:1377 MOTOR PKWY STE 307
Mailing Address - Street 2:
Mailing Address - City:ISLANDIA
Mailing Address - State:NY
Mailing Address - Zip Code:11749-5258
Mailing Address - Country:US
Mailing Address - Phone:631-580-5200
Mailing Address - Fax:631-580-5222
Practice Address - Street 1:5960 FAIRVIEW RD STE 250
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28210-0199
Practice Address - Country:US
Practice Address - Phone:980-224-7958
Practice Address - Fax:980-224-7973
Is Sole Proprietor?:No
Enumeration Date:2016-01-18
Last Update Date:2020-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY039719-1225100000X, 2251S0007X, 2251X0800X
SC8797225100000X
NCP18386225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No2251S0007XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistSports
No2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic