Provider Demographics
NPI:1619990363
Name:KOSTELAC, SHANNON M (MSPT)
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:M
Last Name:KOSTELAC
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 1:509 NURSERY DR S
Mailing Address - Street 2:
Mailing Address - City:MECHANICSBURG
Mailing Address - State:PA
Mailing Address - Zip Code:17055-7020
Mailing Address - Country:US
Mailing Address - Phone:717-790-9953
Mailing Address - Fax:
Practice Address - Street 1:290 E POMFRET ST
Practice Address - Street 2:
Practice Address - City:CARLISLE
Practice Address - State:PA
Practice Address - Zip Code:17013-2579
Practice Address - Country:US
Practice Address - Phone:717-245-0400
Practice Address - Fax:717-243-5688
Is Sole Proprietor?:No
Enumeration Date:2006-07-25
Last Update Date:2015-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPT011740L225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist