Provider Demographics
NPI:1568471753
Name:BLANK, SHANNON DUANE (PT)
Entity type:Individual
Prefix:MR
First Name:SHANNON
Middle Name:DUANE
Last Name:BLANK
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:800 E LOCUST ST
Mailing Address - Street 2:
Mailing Address - City:OLNEY
Mailing Address - State:IL
Mailing Address - Zip Code:62450-2553
Mailing Address - Country:US
Mailing Address - Phone:618-395-6031
Mailing Address - Fax:
Practice Address - Street 1:800 E LOCUST ST
Practice Address - Street 2:
Practice Address - City:OLNEY
Practice Address - State:IL
Practice Address - Zip Code:62450-2553
Practice Address - Country:US
Practice Address - Phone:618-395-6031
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-05
Last Update Date:2010-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL070-010392225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist