Provider Demographics
NPI:1639454192
Name:WELCH, SHANNON B (PT, DPT)
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:B
Last Name:WELCH
Suffix:
Gender:F
Credentials:PT, DPT
Other - Prefix:
Other - First Name:SHANNON
Other - Middle Name:
Other - Last Name:HALL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:58 PORTLAND RD
Mailing Address - Street 2:
Mailing Address - City:SUMMIT
Mailing Address - State:NJ
Mailing Address - Zip Code:07901-3045
Mailing Address - Country:US
Mailing Address - Phone:908-447-1706
Mailing Address - Fax:
Practice Address - Street 1:58 PORTLAND RD
Practice Address - Street 2:
Practice Address - City:SUMMIT
Practice Address - State:NJ
Practice Address - Zip Code:07901-3045
Practice Address - Country:US
Practice Address - Phone:908-447-1706
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-10-17
Last Update Date:2017-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2305207169225100000X
NJ40QA01495000225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist