Provider Demographics
NPI:1720487028
Name:SHOEMAKER, THERESA (PT, DPT)
Entity Type:Individual
Prefix:
First Name:THERESA
Middle Name:
Last Name:SHOEMAKER
Suffix:
Gender:F
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1406 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:RIVERTON
Mailing Address - State:WY
Mailing Address - Zip Code:82501-3239
Mailing Address - Country:US
Mailing Address - Phone:307-857-7074
Mailing Address - Fax:307-856-6459
Practice Address - Street 1:425 LINCOLN ST
Practice Address - Street 2:
Practice Address - City:LANDER
Practice Address - State:WY
Practice Address - Zip Code:82520-2831
Practice Address - Country:US
Practice Address - Phone:307-332-2230
Practice Address - Fax:307-332-0463
Is Sole Proprietor?:Yes
Enumeration Date:2014-08-22
Last Update Date:2022-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO12903225100000X
WYPT-1724225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WY154606600Medicaid
CO12903OtherMEDICARE