Provider Demographics
NPI:1396259750
Name:SHEA, CHRISTINE MARIE
Entity type:Individual
Prefix:
First Name:CHRISTINE
Middle Name:MARIE
Last Name:SHEA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:116 MEIGS ST APT 2
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER
Mailing Address - State:NY
Mailing Address - Zip Code:14607-2035
Mailing Address - Country:US
Mailing Address - Phone:716-913-2338
Mailing Address - Fax:
Practice Address - Street 1:116 MEIGS ST APT 2
Practice Address - Street 2:
Practice Address - City:ROCHESTER
Practice Address - State:NY
Practice Address - Zip Code:14607-2035
Practice Address - Country:US
Practice Address - Phone:716-913-2338
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-11-21
Last Update Date:2017-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY041616225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY041616Medicaid