Provider Demographics
NPI:1598084667
Name:ROSKAMP, SHANNON MARIE (PT, DPT, MSA)
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:MARIE
Last Name:ROSKAMP
Suffix:
Gender:F
Credentials:PT, DPT, MSA
Other - Prefix:
Other - First Name:SHANNON
Other - Middle Name:MARIE
Other - Last Name:KAUFFMAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT, DPT, MSA
Mailing Address - Street 1:50 N COLDWATER RD
Mailing Address - Street 2:STE D
Mailing Address - City:WEIDMAN
Mailing Address - State:MI
Mailing Address - Zip Code:48893-8845
Mailing Address - Country:US
Mailing Address - Phone:989-546-7490
Mailing Address - Fax:989-563-5953
Practice Address - Street 1:50 N COLDWATER RD
Practice Address - Street 2:SUITE D
Practice Address - City:WEIDMAN
Practice Address - State:MI
Practice Address - Zip Code:48893-8845
Practice Address - Country:US
Practice Address - Phone:989-546-7490
Practice Address - Fax:989-546-7298
Is Sole Proprietor?:No
Enumeration Date:2010-05-27
Last Update Date:2017-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5501014675225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI5501014675OtherSTATE LICENSE
MI5501014675OtherSTATE LICENSE