Provider Demographics
NPI:1457083487
Name:BARLOW, SHANNON TARA (PT)
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:TARA
Last Name:BARLOW
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:SHANNON
Other - Middle Name:TARA
Other - Last Name:COOK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1001 N 7TH AVE STE 205
Mailing Address - Street 2:
Mailing Address - City:POCATELLO
Mailing Address - State:ID
Mailing Address - Zip Code:83201-5761
Mailing Address - Country:US
Mailing Address - Phone:208-239-1490
Mailing Address - Fax:208-239-1794
Practice Address - Street 1:1001 N 7TH AVE STE 205
Practice Address - Street 2:
Practice Address - City:POCATELLO
Practice Address - State:ID
Practice Address - Zip Code:83201-5761
Practice Address - Country:US
Practice Address - Phone:208-239-1490
Practice Address - Fax:208-239-1794
Is Sole Proprietor?:Yes
Enumeration Date:2022-06-28
Last Update Date:2022-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDPT-1900261QP2000X, 2081P0010X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2081P0010XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationPediatric Rehabilitation Medicine
No261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy