Provider Demographics
NPI:1215216536
Name:SEPULVEDA, SHANNON EILEEN (DPT)
Entity type:Individual
Prefix:
First Name:SHANNON
Middle Name:EILEEN
Last Name:SEPULVEDA
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 1:415 HENDERSON ST
Mailing Address - Street 2:
Mailing Address - City:BOZEMAN
Mailing Address - State:MT
Mailing Address - Zip Code:59715-3719
Mailing Address - Country:US
Mailing Address - Phone:631-434-5274
Mailing Address - Fax:
Practice Address - Street 1:115 W KAGY BLVD STE D
Practice Address - Street 2:
Practice Address - City:BOZEMAN
Practice Address - State:MT
Practice Address - Zip Code:59715-6043
Practice Address - Country:US
Practice Address - Phone:631-434-5274
Practice Address - Fax:406-272-3404
Is Sole Proprietor?:No
Enumeration Date:2011-08-04
Last Update Date:2021-11-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT2409PT225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist