Provider Demographics
NPI:1417219650
Name:SHOTWELL, ROBERT A (PT)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:A
Last Name:SHOTWELL
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:251 VZCR 1515
Mailing Address - Street 2:
Mailing Address - City:GRAND SALINE
Mailing Address - State:TX
Mailing Address - Zip Code:75140-5635
Mailing Address - Country:US
Mailing Address - Phone:903-714-5579
Mailing Address - Fax:
Practice Address - Street 1:209 E BROADWAY ST
Practice Address - Street 2:
Practice Address - City:WINNSBORO
Practice Address - State:TX
Practice Address - Zip Code:75494-2604
Practice Address - Country:US
Practice Address - Phone:903-342-6790
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-06-13
Last Update Date:2012-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1100080225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist