Provider Demographics
NPI:1770263147
Name:BODILLY, SHANNON (PT, DPT)
Entity type:Individual
Prefix:
First Name:SHANNON
Middle Name:
Last Name:BODILLY
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 1:9004 N PARK PLAZA CT
Mailing Address - Street 2:
Mailing Address - City:BROWN DEER
Mailing Address - State:WI
Mailing Address - Zip Code:53223-2124
Mailing Address - Country:US
Mailing Address - Phone:920-393-0239
Mailing Address - Fax:
Practice Address - Street 1:4241 N US HIGHWAY 1
Practice Address - Street 2:
Practice Address - City:MELBOURNE
Practice Address - State:FL
Practice Address - Zip Code:32935-4822
Practice Address - Country:US
Practice Address - Phone:833-684-5439
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-07-20
Last Update Date:2023-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPT40330225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist