Provider Demographics
NPI:1629742366
Name:DEFUSCO, SHANA (PTA, CPT)
Entity Type:Individual
Prefix:
First Name:SHANA
Middle Name:
Last Name:DEFUSCO
Suffix:
Gender:F
Credentials:PTA, CPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1193 RESERVOIR AVE
Mailing Address - Street 2:
Mailing Address - City:CRANSTON
Mailing Address - State:RI
Mailing Address - Zip Code:02920-6008
Mailing Address - Country:US
Mailing Address - Phone:401-228-3939
Mailing Address - Fax:401-383-3043
Practice Address - Street 1:1193 RESERVOIR AVE
Practice Address - Street 2:
Practice Address - City:CRANSTON
Practice Address - State:RI
Practice Address - Zip Code:02920-6008
Practice Address - Country:US
Practice Address - Phone:401-228-3939
Practice Address - Fax:401-383-3043
Is Sole Proprietor?:Yes
Enumeration Date:2021-08-05
Last Update Date:2021-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIPTA01347225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant