Provider Demographics
NPI:1740613835
Name:AYERS, SHANNON RENA (DPT)
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:RENA
Last Name:AYERS
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 1:450 E. LOOP 281
Mailing Address - Street 2:SUITE B1
Mailing Address - City:LONGVIEW
Mailing Address - State:TX
Mailing Address - Zip Code:75601
Mailing Address - Country:US
Mailing Address - Phone:903-757-7731
Mailing Address - Fax:903-757-3756
Practice Address - Street 1:450 E. LOOP 281
Practice Address - Street 2:SUITE B1
Practice Address - City:LONGVIEW
Practice Address - State:TX
Practice Address - Zip Code:75601
Practice Address - Country:US
Practice Address - Phone:903-757-7731
Practice Address - Fax:903-757-3756
Is Sole Proprietor?:No
Enumeration Date:2013-08-13
Last Update Date:2018-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX12287522251P0200X
AR35372251P0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251P0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR194886721Medicaid