Provider Demographics
NPI:1124306394
Name:BOLGER, SHANNON M (PT, DPT)
Entity type:Individual
Prefix:
First Name:SHANNON
Middle Name:M
Last Name:BOLGER
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 1:3255 BRIGHTON HENRIETTA TOWN LINE RD
Mailing Address - Street 2:SUITE 102
Mailing Address - City:ROCHESTER
Mailing Address - State:NY
Mailing Address - Zip Code:14623-2806
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3255 BRIGHTON HENRIETTA TOWN LINE RD
Practice Address - Street 2:SUITE 102
Practice Address - City:ROCHESTER
Practice Address - State:NY
Practice Address - Zip Code:14623-2806
Practice Address - Country:US
Practice Address - Phone:585-427-2977
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-07-21
Last Update Date:2011-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0340962251P0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251P0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistPediatrics