Provider Demographics
NPI:1669684031
Name:MACDONALD, SHALLYN F (PT)
Entity Type:Individual
Prefix:DR
First Name:SHALLYN
Middle Name:F
Last Name:MACDONALD
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:SHALLYN
Other - Middle Name:F
Other - Last Name:HANSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT DPT OCS FAAOMPT
Mailing Address - Street 1:14950 WELLWOOD DR
Mailing Address - Street 2:
Mailing Address - City:ELBERT
Mailing Address - State:CO
Mailing Address - Zip Code:80106
Mailing Address - Country:US
Mailing Address - Phone:719-219-5865
Mailing Address - Fax:719-799-6948
Practice Address - Street 1:14950 WELLWOOD DR
Practice Address - Street 2:
Practice Address - City:ELBERT
Practice Address - State:CO
Practice Address - Zip Code:80106
Practice Address - Country:US
Practice Address - Phone:719-219-5865
Practice Address - Fax:719-799-6948
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-05
Last Update Date:2019-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO7810225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
COC803849Medicare UPIN