Provider Demographics
NPI:1346592300
Name:PERKINS, SHAUNTAE (DPT)
Entity Type:Individual
Prefix:
First Name:SHAUNTAE
Middle Name:
Last Name:PERKINS
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1930 E SOUTHERN AVE
Mailing Address - Street 2:
Mailing Address - City:TEMPE
Mailing Address - State:AZ
Mailing Address - Zip Code:85282-7518
Mailing Address - Country:US
Mailing Address - Phone:480-456-0719
Mailing Address - Fax:480-456-0163
Practice Address - Street 1:1930 E SOUTHERN AVE
Practice Address - Street 2:
Practice Address - City:TEMPE
Practice Address - State:AZ
Practice Address - Zip Code:85282-7518
Practice Address - Country:US
Practice Address - Phone:480-456-0719
Practice Address - Fax:480-456-0163
Is Sole Proprietor?:Yes
Enumeration Date:2012-10-15
Last Update Date:2012-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ9993225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ747240Medicaid