Provider Demographics
NPI:1851771216
Name:WITHERSPOON, SHANNON (PT/DPT)
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:
Last Name:WITHERSPOON
Suffix:
Gender:F
Credentials:PT/DPT
Other - Prefix:
Other - First Name:SHANNON
Other - Middle Name:
Other - Last Name:MOATS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1431 IYANNOUGH RD
Mailing Address - Street 2:UNIT 2
Mailing Address - City:CENTERVILLE
Mailing Address - State:MA
Mailing Address - Zip Code:02632-1989
Mailing Address - Country:US
Mailing Address - Phone:315-723-9047
Mailing Address - Fax:
Practice Address - Street 1:209 COUNTY RD
Practice Address - Street 2:
Practice Address - City:NORTH FALMOUTH
Practice Address - State:MA
Practice Address - Zip Code:02556-2021
Practice Address - Country:US
Practice Address - Phone:508-563-4042
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-06-01
Last Update Date:2019-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA20341225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist