Provider Demographics
NPI:1023168697
Name:CLIFFORD, SHANNON (PT)
Entity type:Individual
Prefix:
First Name:SHANNON
Middle Name:
Last Name:CLIFFORD
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:611 NEW RD
Mailing Address - Street 2:
Mailing Address - City:NORTHFIELD
Mailing Address - State:NJ
Mailing Address - Zip Code:08225-1669
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:611 NEW RD
Practice Address - Street 2:
Practice Address - City:NORTHFIELD
Practice Address - State:NJ
Practice Address - Zip Code:08225-1669
Practice Address - Country:US
Practice Address - Phone:609-645-2514
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-12
Last Update Date:2010-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPT015941225100000X
NJ40QA01382700225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV1060416OtherWORKERS COMP
PA1418430OtherHIGHMARK
PA0019168370003Medicaid