Provider Demographics
NPI:1407588528
Name:BUCHWALD, SHANNON LEE (DPT)
Entity type:Individual
Prefix:
First Name:SHANNON
Middle Name:LEE
Last Name:BUCHWALD
Suffix:
Gender:
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2222 CHERRY ST STE 1900
Mailing Address - Street 2:
Mailing Address - City:TOLEDO
Mailing Address - State:OH
Mailing Address - Zip Code:43608-2673
Mailing Address - Country:US
Mailing Address - Phone:419-251-3878
Mailing Address - Fax:
Practice Address - Street 1:3930 SUNFOREST CT STE 200
Practice Address - Street 2:
Practice Address - City:TOLEDO
Practice Address - State:OH
Practice Address - Zip Code:43623-4441
Practice Address - Country:US
Practice Address - Phone:419-251-0070
Practice Address - Fax:419-251-0075
Is Sole Proprietor?:No
Enumeration Date:2022-06-28
Last Update Date:2025-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHPT016674225100000X, 2251P0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251P0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistPediatrics
No225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0027365Medicaid