Provider Demographics
NPI:1609068774
Name:BREWER, SHANNA ELIZABETH (ATC)
Entity Type:Individual
Prefix:MRS
First Name:SHANNA
Middle Name:ELIZABETH
Last Name:BREWER
Suffix:
Gender:F
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4415 BEVINGTON LN APT B
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46240-4400
Mailing Address - Country:US
Mailing Address - Phone:317-292-3155
Mailing Address - Fax:
Practice Address - Street 1:4330 MICHIGAN RD
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46208-3324
Practice Address - Country:US
Practice Address - Phone:317-292-3155
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-08-13
Last Update Date:2012-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN36001913A2255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer