Provider Demographics
NPI:1942502950
Name:TREADWELL, SHANNA L (PT)
Entity Type:Individual
Prefix:MRS
First Name:SHANNA
Middle Name:L
Last Name:TREADWELL
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:SHANNA
Other - Middle Name:L
Other - Last Name:ANDREWS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT
Mailing Address - Street 1:346 GRAND AVE
Mailing Address - Street 2:
Mailing Address - City:JOHNSON CITY
Mailing Address - State:NY
Mailing Address - Zip Code:13790-2580
Mailing Address - Country:US
Mailing Address - Phone:607-729-8156
Mailing Address - Fax:607-729-3982
Practice Address - Street 1:91 CHENANGO BRIDGE RD
Practice Address - Street 2:
Practice Address - City:BINGHAMTON
Practice Address - State:NY
Practice Address - Zip Code:13901-1293
Practice Address - Country:US
Practice Address - Phone:607-648-9292
Practice Address - Fax:607-648-7270
Is Sole Proprietor?:No
Enumeration Date:2010-11-23
Last Update Date:2011-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY033404225100000X
NYP78218225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY03296820Medicaid
NY03296820Medicaid