Provider Demographics
NPI:1801463120
Name:RICHARDSON, SHANNON KATHLEEN (PT, DPT, NCS, MBA)
Entity type:Individual
Prefix:
First Name:SHANNON
Middle Name:KATHLEEN
Last Name:RICHARDSON
Suffix:
Gender:F
Credentials:PT, DPT, NCS, MBA
Other - Prefix:
Other - First Name:SHANNON
Other - Middle Name:KATHLEEN
Other - Last Name:MARRINER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT, DPT, NCS, MBA
Mailing Address - Street 1:PO BOX 30532
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19103-8532
Mailing Address - Country:US
Mailing Address - Phone:215-469-1832
Mailing Address - Fax:
Practice Address - Street 1:1923 BAINBRIDGE ST
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19146-1430
Practice Address - Country:US
Practice Address - Phone:215-469-1832
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-06-06
Last Update Date:2021-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPT021322225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist