Provider Demographics
NPI:1659502854
Name:O'TOOLE, SHANNON M (PT)
Entity type:Individual
Prefix:
First Name:SHANNON
Middle Name:M
Last Name:O'TOOLE
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 1:551 RIVERHILL CIR
Mailing Address - Street 2:# 921
Mailing Address - City:COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29210-8156
Mailing Address - Country:US
Mailing Address - Phone:636-795-3693
Mailing Address - Fax:
Practice Address - Street 1:132B SUNSET COURT
Practice Address - Street 2:
Practice Address - City:WEST COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29169
Practice Address - Country:US
Practice Address - Phone:803-796-5116
Practice Address - Fax:803-796-5131
Is Sole Proprietor?:No
Enumeration Date:2009-08-05
Last Update Date:2009-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SCPT6005225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC8644Medicare PIN