Provider Demographics
NPI:1790592368
Name:STEWART, SHANNON DOLORES (PTA)
Entity type:Individual
Prefix:
First Name:SHANNON
Middle Name:DOLORES
Last Name:STEWART
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:106 INDIAN CREEK WAY
Mailing Address - Street 2:
Mailing Address - City:CHALFONT
Mailing Address - State:PA
Mailing Address - Zip Code:18914-2138
Mailing Address - Country:US
Mailing Address - Phone:215-500-7676
Mailing Address - Fax:
Practice Address - Street 1:25 W 5TH ST
Practice Address - Street 2:
Practice Address - City:LANSDALE
Practice Address - State:PA
Practice Address - Zip Code:19446-2424
Practice Address - Country:US
Practice Address - Phone:215-855-9765
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-12-16
Last Update Date:2024-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PATEI006533208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation