Provider Demographics
NPI:1104226646
Name:BAIS, SHANNON LEE (PT, DPT)
Entity type:Individual
Prefix:
First Name:SHANNON
Middle Name:LEE
Last Name:BAIS
Suffix:
Gender:F
Credentials:PT, DPT
Other - Prefix:
Other - First Name:SHANNON
Other - Middle Name:LEE
Other - Last Name:POST
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT, DPT
Mailing Address - Street 1:239 BROWN AVE
Mailing Address - Street 2:
Mailing Address - City:PROSPECT PARK
Mailing Address - State:NJ
Mailing Address - Zip Code:07508-1842
Mailing Address - Country:US
Mailing Address - Phone:973-557-5790
Mailing Address - Fax:
Practice Address - Street 1:605 MAIN ST
Practice Address - Street 2:
Practice Address - City:HACKENSACK
Practice Address - State:NJ
Practice Address - Zip Code:07601-5914
Practice Address - Country:US
Practice Address - Phone:201-488-0488
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-09-03
Last Update Date:2018-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ40QA015701002251X0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedicGroup - Single Specialty