Provider Demographics
NPI:1346722337
Name:LOUIS, SHANNA
Entity Type:Individual
Prefix:
First Name:SHANNA
Middle Name:
Last Name:LOUIS
Suffix:
Gender:F
Credentials:
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 1146
Mailing Address - Street 2:
Mailing Address - City:LA VERNIA
Mailing Address - State:TX
Mailing Address - Zip Code:78121-1146
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4211 GARDENDALE ST STE 200A
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78229-3529
Practice Address - Country:US
Practice Address - Phone:210-615-7837
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-09-05
Last Update Date:2018-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
2039030225200000X
TX2039030225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1578708483Medicaid
TX1124259502Medicaid