Provider Demographics
NPI:1720115405
Name:MERRICK, WILLIAM SHANNON (PT, ATC)
Entity Type:Individual
Prefix:MR
First Name:WILLIAM
Middle Name:SHANNON
Last Name:MERRICK
Suffix:
Gender:M
Credentials:PT, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3903 NORTHDALE BLVD
Mailing Address - Street 2:STE 111W
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33624-1864
Mailing Address - Country:US
Mailing Address - Phone:813-418-7350
Mailing Address - Fax:
Practice Address - Street 1:21756 STATE ROAD 54
Practice Address - Street 2:STE 102
Practice Address - City:LUTZ
Practice Address - State:FL
Practice Address - Zip Code:33549-2905
Practice Address - Country:US
Practice Address - Phone:813-279-6234
Practice Address - Fax:813-949-1927
Is Sole Proprietor?:No
Enumeration Date:2007-02-28
Last Update Date:2017-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPT-00103052251X0800X
FLAL 17092255A2300X
FLPT10305225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer