Provider Demographics
NPI:1992818785
Name:SNIDER, SHANNON DALE (P T, CSCS)
Entity type:Individual
Prefix:MR
First Name:SHANNON
Middle Name:DALE
Last Name:SNIDER
Suffix:
Gender:M
Credentials:P T, CSCS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 615
Mailing Address - Street 2:309 LAGRANGE RD.
Mailing Address - City:PEWEE VALLEY
Mailing Address - State:KY
Mailing Address - Zip Code:40056-0615
Mailing Address - Country:US
Mailing Address - Phone:502-243-6868
Mailing Address - Fax:502-243-6867
Practice Address - Street 1:309 LA GRANGE RD
Practice Address - Street 2:
Practice Address - City:PEWEE VALLEY
Practice Address - State:KY
Practice Address - Zip Code:40056-9168
Practice Address - Country:US
Practice Address - Phone:502-243-6868
Practice Address - Fax:502-243-6867
Is Sole Proprietor?:No
Enumeration Date:2006-08-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY003490225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY5025801Medicare ID - Type Unspecified