Provider Demographics
NPI:1710941455
Name:ERICSON, SHANNON B (MS, PT)
Entity Type:Individual
Prefix:MR
First Name:SHANNON
Middle Name:B
Last Name:ERICSON
Suffix:
Gender:M
Credentials:MS, PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5425 W 100TH TER
Mailing Address - Street 2:
Mailing Address - City:OVERLAND PARK
Mailing Address - State:KS
Mailing Address - Zip Code:66207-3119
Mailing Address - Country:US
Mailing Address - Phone:913-825-6636
Mailing Address - Fax:
Practice Address - Street 1:5425 W 100TH TER
Practice Address - Street 2:
Practice Address - City:OVERLAND PARK
Practice Address - State:KS
Practice Address - Zip Code:66207-3119
Practice Address - Country:US
Practice Address - Phone:913-825-6636
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-04-12
Last Update Date:2007-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS11-01600225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist