Provider Demographics
NPI:1437888724
Name:COOLEY, SHANNON NICOLE (PT, DPT)
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:NICOLE
Last Name:COOLEY
Suffix:
Gender:F
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 1:9124 CHARTERHOUSE RD
Mailing Address - Street 2:
Mailing Address - City:FREDERICK
Mailing Address - State:MD
Mailing Address - Zip Code:21704-7327
Mailing Address - Country:US
Mailing Address - Phone:240-446-4780
Mailing Address - Fax:
Practice Address - Street 1:5223 BUCKEYSTOWN PIKE STE 158
Practice Address - Street 2:
Practice Address - City:FREDERICK
Practice Address - State:MD
Practice Address - Zip Code:21704-7535
Practice Address - Country:US
Practice Address - Phone:301-662-6790
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-06-10
Last Update Date:2022-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2305215071208100000X
MD28996225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation