Provider Demographics
NPI:1699802553
Name:BENNER-ERICKSON, SHAWNA ELISA (MPT)
Entity type:Individual
Prefix:
First Name:SHAWNA
Middle Name:ELISA
Last Name:BENNER-ERICKSON
Suffix:
Gender:F
Credentials:MPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1005 HIGHWAY 2
Mailing Address - Street 2:
Mailing Address - City:SANDPOINT
Mailing Address - State:ID
Mailing Address - Zip Code:83864-1702
Mailing Address - Country:US
Mailing Address - Phone:208-263-1632
Mailing Address - Fax:208-255-2066
Practice Address - Street 1:1005 HIGHWAY 2
Practice Address - Street 2:
Practice Address - City:SANDPOINT
Practice Address - State:ID
Practice Address - Zip Code:83864-1702
Practice Address - Country:US
Practice Address - Phone:208-263-1632
Practice Address - Fax:208-255-2066
Is Sole Proprietor?:No
Enumeration Date:2007-02-27
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDPT 1783225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID000010152747OtherBLUE SHIELD
IDTD256OtherBLUECROSS# IN GROUP 8M558
IDTD256OtherBLUECROSS# IN GROUP 8M558
IDEXEMPTMedicare UPIN