Provider Demographics
NPI:1427536291
Name:LILLIE, SHAWN THOMAS (PT, DPT)
Entity Type:Individual
Prefix:
First Name:SHAWN
Middle Name:THOMAS
Last Name:LILLIE
Suffix:
Gender:M
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10931 ROCKY LEDGE LN
Mailing Address - Street 2:
Mailing Address - City:PAINESVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:44077-8605
Mailing Address - Country:US
Mailing Address - Phone:315-262-4927
Mailing Address - Fax:
Practice Address - Street 1:8836 TYLER BLVD
Practice Address - Street 2:
Practice Address - City:MENTOR
Practice Address - State:OH
Practice Address - Zip Code:44060-4361
Practice Address - Country:US
Practice Address - Phone:440-255-9553
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-08-02
Last Update Date:2018-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist