Provider Demographics
NPI:1881091692
Name:HENRY, SHAWNELL (PT, DPT)
Entity type:Individual
Prefix:
First Name:SHAWNELL
Middle Name:
Last Name:HENRY
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 1:493 VALLEY ST APT 16
Mailing Address - Street 2:
Mailing Address - City:ORANGE
Mailing Address - State:NJ
Mailing Address - Zip Code:07050-1257
Mailing Address - Country:US
Mailing Address - Phone:973-738-7673
Mailing Address - Fax:
Practice Address - Street 1:493 VALLEY ST APT 16
Practice Address - Street 2:
Practice Address - City:ORANGE
Practice Address - State:NJ
Practice Address - Zip Code:07050-1257
Practice Address - Country:US
Practice Address - Phone:973-738-7673
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-11-21
Last Update Date:2018-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ40QA01583900225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ40QA01583900Medicare UPIN