Provider Demographics
NPI:1568011492
Name:FLORENCE, SHANE WILLIAM (MPT)
Entity Type:Individual
Prefix:MR
First Name:SHANE
Middle Name:WILLIAM
Last Name:FLORENCE
Suffix:
Gender:M
Credentials:MPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:520 W 41ST ST
Mailing Address - Street 2:
Mailing Address - City:SHADYSIDE
Mailing Address - State:OH
Mailing Address - Zip Code:43947-1171
Mailing Address - Country:US
Mailing Address - Phone:740-232-4707
Mailing Address - Fax:
Practice Address - Street 1:520 W 41ST ST
Practice Address - Street 2:
Practice Address - City:SHADYSIDE
Practice Address - State:OH
Practice Address - Zip Code:43947-1171
Practice Address - Country:US
Practice Address - Phone:740-232-4707
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-09-04
Last Update Date:2020-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WVPT002541225100000X
OHPT009871225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist