Provider Demographics
NPI:1114003019
Name:ADCOCK, SHANNON (DPT)
Entity type:Individual
Prefix:
First Name:SHANNON
Middle Name:
Last Name:ADCOCK
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18051 RIVER AVE
Mailing Address - Street 2:SUITE 200
Mailing Address - City:NOBLESVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:46062-7091
Mailing Address - Country:US
Mailing Address - Phone:317-773-0002
Mailing Address - Fax:
Practice Address - Street 1:18051 RIVER AVE
Practice Address - Street 2:SUITE 200
Practice Address - City:NOBLESVILLE
Practice Address - State:IN
Practice Address - Zip Code:46062-7091
Practice Address - Country:US
Practice Address - Phone:317-773-0002
Practice Address - Fax:317-776-6095
Is Sole Proprietor?:No
Enumeration Date:2006-10-31
Last Update Date:2010-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN05008779225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200801180Medicaid
P00405478Medicare PIN
INQ56359Medicare UPIN
IN200801180Medicaid
IN151560QQMedicare PIN