Provider Demographics
NPI:1992999254
Name:REEDER, SHANNON ALEXANDRIA (PTA)
Entity type:Individual
Prefix:MRS
First Name:SHANNON
Middle Name:ALEXANDRIA
Last Name:REEDER
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1155 MALABAR RD NE
Mailing Address - Street 2:SUITE 13
Mailing Address - City:PALM BAY
Mailing Address - State:FL
Mailing Address - Zip Code:32907-3245
Mailing Address - Country:US
Mailing Address - Phone:321-409-5777
Mailing Address - Fax:321-409-5888
Practice Address - Street 1:1155 MALABAR RD NE
Practice Address - Street 2:SUITE 13
Practice Address - City:PALM BAY
Practice Address - State:FL
Practice Address - Zip Code:32907-3245
Practice Address - Country:US
Practice Address - Phone:321-409-5777
Practice Address - Fax:321-409-5888
Is Sole Proprietor?:No
Enumeration Date:2007-08-30
Last Update Date:2007-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPTA18095225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant