Provider Demographics
NPI:1831306117
Name:STEWART, SHANNA L (MPT)
Entity Type:Individual
Prefix:
First Name:SHANNA
Middle Name:L
Last Name:STEWART
Suffix:
Gender:F
Credentials:MPT
Other - Prefix:
Other - First Name:SHANNA
Other - Middle Name:L
Other - Last Name:PEDERSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MPT
Mailing Address - Street 1:17134 BEL RAY PL
Mailing Address - Street 2:
Mailing Address - City:BELTON
Mailing Address - State:MO
Mailing Address - Zip Code:64012-5331
Mailing Address - Country:US
Mailing Address - Phone:816-226-4011
Mailing Address - Fax:816-524-6115
Practice Address - Street 1:7211 W 110TH ST
Practice Address - Street 2:
Practice Address - City:OVERLAND PARK
Practice Address - State:KS
Practice Address - Zip Code:66210-2339
Practice Address - Country:US
Practice Address - Phone:913-451-7372
Practice Address - Fax:913-451-7375
Is Sole Proprietor?:No
Enumeration Date:2007-05-17
Last Update Date:2014-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS11-03699225100000X
MO2005019715225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
KSKA2868011OtherMEDICARE PTAN
MOMA4370024OtherMEDICARE PTAN
38359117OtherBCBS KC
KS38359067OtherBCBS
MO38359107OtherBCBS KC
KSQ69F267Medicare PIN