Provider Demographics
NPI:1982287561
Name:HRESKO, SHANNON RUTH (PT)
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:RUTH
Last Name:HRESKO
Suffix:
Gender:F
Credentials:PT
Other - Prefix:MRS
Other - First Name:SHANNON
Other - Middle Name:
Other - Last Name:HRESKO
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PT
Mailing Address - Street 1:100 SUNSET DR
Mailing Address - Street 2:
Mailing Address - City:YOUNGSVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:27596-9403
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:100 SUNSET DR
Practice Address - Street 2:
Practice Address - City:YOUNGSVILLE
Practice Address - State:NC
Practice Address - Zip Code:27596-9403
Practice Address - Country:US
Practice Address - Phone:919-562-5550
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-05-03
Last Update Date:2021-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCP10630225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist