Provider Demographics
NPI:1881707305
Name:SHUFFLEBARGER, KATHY J (PT)
Entity type:Individual
Prefix:
First Name:KATHY
Middle Name:J
Last Name:SHUFFLEBARGER
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1215 E ORANGE ST
Mailing Address - Street 2:
Mailing Address - City:LAKELAND
Mailing Address - State:FL
Mailing Address - Zip Code:33801-5762
Mailing Address - Country:US
Mailing Address - Phone:863-802-3800
Mailing Address - Fax:863-802-0480
Practice Address - Street 1:1215 E ORANGE ST
Practice Address - Street 2:
Practice Address - City:LAKELAND
Practice Address - State:FL
Practice Address - Zip Code:33801-5762
Practice Address - Country:US
Practice Address - Phone:863-802-3800
Practice Address - Fax:863-802-0480
Is Sole Proprietor?:No
Enumeration Date:2006-08-17
Last Update Date:2011-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPT1944225100000X, 222Q00000X
FLPT00019442251P0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist
No2251P0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL880329300Medicaid
FL1342502OtherINDIVIDUAL CITRUS HEALTH
FLPT1944OtherFLORIDA PT LICENSE
FLY905LOtherBCBS FL