Provider Demographics
NPI:1902806896
Name:SHECKELS, SHANNON (PT)
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:
Last Name:SHECKELS
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:350 NEW FIDELITY CT
Mailing Address - Street 2:
Mailing Address - City:GARNER
Mailing Address - State:NC
Mailing Address - Zip Code:27529-2665
Mailing Address - Country:US
Mailing Address - Phone:919-258-2714
Mailing Address - Fax:410-648-4878
Practice Address - Street 1:1207 LIBERTY RD STE 106
Practice Address - Street 2:
Practice Address - City:ELDERSBURG
Practice Address - State:MD
Practice Address - Zip Code:21784-6574
Practice Address - Country:US
Practice Address - Phone:410-549-5700
Practice Address - Fax:410-549-6200
Is Sole Proprietor?:No
Enumeration Date:2005-07-21
Last Update Date:2018-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD18634225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
2118118OtherAETNA HMO
DCT615-0007OtherCAREFIRST BLUECHOICE
5060511OtherAETNA NON HMO
284114OtherMAMSI
MD216588Medicare ID - Type UnspecifiedMEDICARE MARYLAND
MDH481-55000303OtherCAREFIRST BLUECROSS