Provider Demographics
NPI:1598743999
Name:FORRESTALL, SHANNON M (MSPT)
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:M
Last Name:FORRESTALL
Suffix:
Gender:F
Credentials:MSPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1655 CAPITOL ST NE
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:OR
Mailing Address - Zip Code:97301-7845
Mailing Address - Country:US
Mailing Address - Phone:503-983-8811
Mailing Address - Fax:503-364-1376
Practice Address - Street 1:1655 CAPITOL ST NE
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:OR
Practice Address - Zip Code:97301-7845
Practice Address - Country:US
Practice Address - Phone:503-983-8811
Practice Address - Fax:503-364-1376
Is Sole Proprietor?:No
Enumeration Date:2006-01-05
Last Update Date:2022-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
225100000X
OR3693225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR274832Medicaid
ORR141499Medicare PIN