Provider Demographics
NPI:1528355864
Name:SMITH, SHANNON MARIE (DPT)
Entity type:Individual
Prefix:
First Name:SHANNON
Middle Name:MARIE
Last Name:SMITH
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 1:4635 UNION RD
Mailing Address - Street 2:
Mailing Address - City:BUFFALO
Mailing Address - State:NY
Mailing Address - Zip Code:14225-1851
Mailing Address - Country:US
Mailing Address - Phone:716-817-5220
Mailing Address - Fax:716-633-9351
Practice Address - Street 1:4635 UNION RD
Practice Address - Street 2:
Practice Address - City:BUFFALO
Practice Address - State:NY
Practice Address - Zip Code:14225-1851
Practice Address - Country:US
Practice Address - Phone:716-817-5220
Practice Address - Fax:716-633-9351
Is Sole Proprietor?:No
Enumeration Date:2011-07-07
Last Update Date:2013-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0339392251P0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251P0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistPediatrics