Provider Demographics
NPI:1689781593
Name:FAMILLE, SHANE (PT, ATC)
Entity Type:Individual
Prefix:MR
First Name:SHANE
Middle Name:
Last Name:FAMILLE
Suffix:
Gender:M
Credentials:PT, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17 11TH AVE
Mailing Address - Street 2:
Mailing Address - City:GLENDORA
Mailing Address - State:NJ
Mailing Address - Zip Code:08029-1333
Mailing Address - Country:US
Mailing Address - Phone:856-216-0047
Mailing Address - Fax:856-427-9314
Practice Address - Street 1:17 11TH AVE
Practice Address - Street 2:
Practice Address - City:GLENDORA
Practice Address - State:NJ
Practice Address - Zip Code:08029-1333
Practice Address - Country:US
Practice Address - Phone:856-216-0047
Practice Address - Fax:856-427-9314
Is Sole Proprietor?:No
Enumeration Date:2006-08-24
Last Update Date:2010-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MT001256002255A2300X
NJ40QA013178002251S0007X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251S0007XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistSports
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer