Provider Demographics
NPI:1780229898
Name:RAVENELLE, SHANE (PT, DPT)
Entity Type:Individual
Prefix:
First Name:SHANE
Middle Name:
Last Name:RAVENELLE
Suffix:
Gender:M
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3230 E IMPERIAL HWY STE 100
Mailing Address - Street 2:
Mailing Address - City:BREA
Mailing Address - State:CA
Mailing Address - Zip Code:92821-6735
Mailing Address - Country:US
Mailing Address - Phone:714-988-8110
Mailing Address - Fax:714-988-8111
Practice Address - Street 1:24301 MUIRLANDS BLVD STE T
Practice Address - Street 2:
Practice Address - City:LAKE FOREST
Practice Address - State:CA
Practice Address - Zip Code:92630-3627
Practice Address - Country:US
Practice Address - Phone:949-271-0012
Practice Address - Fax:949-271-0013
Is Sole Proprietor?:No
Enumeration Date:2019-11-12
Last Update Date:2019-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA297650225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist