Provider Demographics
NPI:1992405302
Name:RODERIQUE, SHANNON RAYE (LPTA)
Entity type:Individual
Prefix:MRS
First Name:SHANNON
Middle Name:RAYE
Last Name:RODERIQUE
Suffix:
Gender:F
Credentials:LPTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7068 S OUTER 364
Mailing Address - Street 2:
Mailing Address - City:O FALLON
Mailing Address - State:MO
Mailing Address - Zip Code:63368-7757
Mailing Address - Country:US
Mailing Address - Phone:636-240-6100
Mailing Address - Fax:
Practice Address - Street 1:7068 S OUTER 364
Practice Address - Street 2:
Practice Address - City:O FALLON
Practice Address - State:MO
Practice Address - Zip Code:63368-7757
Practice Address - Country:US
Practice Address - Phone:636-240-6100
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-03-06
Last Update Date:2023-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy AssistantGroup - Multi-Specialty