Provider Demographics
NPI:1245439975
Name:SPADY, SHANNON ELIZABETH (MPT)
Entity type:Individual
Prefix:
First Name:SHANNON
Middle Name:ELIZABETH
Last Name:SPADY
Suffix:
Gender:F
Credentials:MPT
Other - Prefix:
Other - First Name:SHANNON
Other - Middle Name:ELIZABETH
Other - Last Name:FACKLER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:4014J MOUNTVILLE RD
Mailing Address - Street 2:
Mailing Address - City:JEFFERSON
Mailing Address - State:MD
Mailing Address - Zip Code:21755-7713
Mailing Address - Country:US
Mailing Address - Phone:301-473-5900
Mailing Address - Fax:301-473-5901
Practice Address - Street 1:4014J MOUNTVILLE RD
Practice Address - Street 2:
Practice Address - City:JEFFERSON
Practice Address - State:MD
Practice Address - Zip Code:21755-7713
Practice Address - Country:US
Practice Address - Phone:301-473-5900
Practice Address - Fax:301-473-5901
Is Sole Proprietor?:No
Enumeration Date:2007-07-12
Last Update Date:2007-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD22247225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
DC022180A58Medicare PIN
MDH258R505Medicare PIN