Provider Demographics
NPI:1740473982
Name:MASTIN, SHANNON MARIE (MSPT)
Entity type:Individual
Prefix:
First Name:SHANNON
Middle Name:MARIE
Last Name:MASTIN
Suffix:
Gender:F
Credentials:MSPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:244 E MONTGOMERY AVE
Mailing Address - Street 2:APT C-1
Mailing Address - City:ARDMORE
Mailing Address - State:PA
Mailing Address - Zip Code:19003-3343
Mailing Address - Country:US
Mailing Address - Phone:585-330-0360
Mailing Address - Fax:
Practice Address - Street 1:244 E MONTGOMERY AVE
Practice Address - Street 2:APT C-1
Practice Address - City:ARDMORE
Practice Address - State:PA
Practice Address - Zip Code:19003-3343
Practice Address - Country:US
Practice Address - Phone:585-330-0360
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-08-21
Last Update Date:2007-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPT018196225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist