Provider Demographics
NPI:1801208111
Name:MANNING, SHANNON RAE (DPT, OTR/L)
Entity Type:Individual
Prefix:DR
First Name:SHANNON
Middle Name:RAE
Last Name:MANNING
Suffix:
Gender:F
Credentials:DPT, OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:102 E 9TH ST
Mailing Address - Street 2:
Mailing Address - City:KAUFMAN
Mailing Address - State:TX
Mailing Address - Zip Code:75142-3226
Mailing Address - Country:US
Mailing Address - Phone:972-834-0546
Mailing Address - Fax:
Practice Address - Street 1:102 E 9TH ST
Practice Address - Street 2:
Practice Address - City:KAUFMAN
Practice Address - State:TX
Practice Address - Zip Code:75142-3226
Practice Address - Country:US
Practice Address - Phone:972-834-0546
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-05-21
Last Update Date:2020-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1317654225100000X
TX116481225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty
No225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1801208111Medicaid