Provider Demographics
NPI:1992943823
Name:CARPENTER, SHANE C (DPT)
Entity type:Individual
Prefix:MRS
First Name:SHANE
Middle Name:C
Last Name:CARPENTER
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 1:2033 SAN ELIJO AVE # 111
Mailing Address - Street 2:
Mailing Address - City:CARDIFF
Mailing Address - State:CA
Mailing Address - Zip Code:92007-1726
Mailing Address - Country:US
Mailing Address - Phone:760-557-0760
Mailing Address - Fax:
Practice Address - Street 1:2033 SAN ELIJO AVE
Practice Address - Street 2:#111
Practice Address - City:CARDIFF
Practice Address - State:CA
Practice Address - Zip Code:92007-1726
Practice Address - Country:US
Practice Address - Phone:831-419-8856
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-01-30
Last Update Date:2022-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA35208225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist