Provider Demographics
NPI:1659155810
Name:HADDOW, SHANNA (DPT)
Entity Type:Individual
Prefix:MISS
First Name:SHANNA
Middle Name:
Last Name:HADDOW
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:191 PATCHOGUE YAPHANK RD
Mailing Address - Street 2:
Mailing Address - City:EAST PATCHOGUE
Mailing Address - State:NY
Mailing Address - Zip Code:11772-4899
Mailing Address - Country:US
Mailing Address - Phone:631-775-0971
Mailing Address - Fax:631-475-0975
Practice Address - Street 1:159 ISLIP AVE
Practice Address - Street 2:
Practice Address - City:ISLIP
Practice Address - State:NY
Practice Address - Zip Code:11751-3210
Practice Address - Country:US
Practice Address - Phone:631-650-6347
Practice Address - Fax:631-650-6346
Is Sole Proprietor?:No
Enumeration Date:2023-08-21
Last Update Date:2023-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY050850225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist