Provider Demographics
NPI:1891192647
Name:BLACKMAN, SHANA (DPT)
Entity Type:Individual
Prefix:
First Name:SHANA
Middle Name:
Last Name:BLACKMAN
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 1:2560 N 81ST ST
Mailing Address - Street 2:
Mailing Address - City:WAUWATOSA
Mailing Address - State:WI
Mailing Address - Zip Code:53213-1015
Mailing Address - Country:US
Mailing Address - Phone:414-479-0776
Mailing Address - Fax:
Practice Address - Street 1:1139 S SUNNYSLOPE DR
Practice Address - Street 2:SUITE 203
Practice Address - City:MOUNT PLEASANT
Practice Address - State:WI
Practice Address - Zip Code:53406-3998
Practice Address - Country:US
Practice Address - Phone:262-321-0240
Practice Address - Fax:262-321-0242
Is Sole Proprietor?:Yes
Enumeration Date:2014-11-21
Last Update Date:2014-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI11775-024225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist