Provider Demographics
NPI:1801049960
Name:SHAVER, COLEEN TERI
Entity type:Individual
Prefix:
First Name:COLEEN
Middle Name:TERI
Last Name:SHAVER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4400 CEDARVALE RD
Mailing Address - Street 2:
Mailing Address - City:SYRACUSE
Mailing Address - State:NY
Mailing Address - Zip Code:13215-9696
Mailing Address - Country:US
Mailing Address - Phone:315-469-3407
Mailing Address - Fax:
Practice Address - Street 1:4400 CEDARVALE RD
Practice Address - Street 2:
Practice Address - City:SYRACUSE
Practice Address - State:NY
Practice Address - Zip Code:13215-9696
Practice Address - Country:US
Practice Address - Phone:315-469-3407
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-11-02
Last Update Date:2008-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY005371-12251P0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251P0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistPediatrics