Provider Demographics
NPI:1508039264
Name:FARRELL, SHANNON RAE (PT)
Entity Type:Individual
Prefix:MS
First Name:SHANNON
Middle Name:RAE
Last Name:FARRELL
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7440 N SHADELAND AVE
Mailing Address - Street 2:130
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46250-2029
Mailing Address - Country:US
Mailing Address - Phone:317-577-7333
Mailing Address - Fax:317-577-7330
Practice Address - Street 1:7440 N SHADELAND AVE
Practice Address - Street 2:130
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46250-2029
Practice Address - Country:US
Practice Address - Phone:317-577-7333
Practice Address - Fax:317-577-7330
Is Sole Proprietor?:No
Enumeration Date:2008-04-02
Last Update Date:2008-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN05002490A225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN05002490AOtherPROFESSIONAL LINCENSE