Provider Demographics
NPI:1548490444
Name:ANDERSON, SHANNON TODD (DPT)
Entity type:Individual
Prefix:
First Name:SHANNON
Middle Name:TODD
Last Name:ANDERSON
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12023 WANDSWORTH DR
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33626-2614
Mailing Address - Country:US
Mailing Address - Phone:813-891-9943
Mailing Address - Fax:
Practice Address - Street 1:12023 WANDSWORTH DR
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33626-2614
Practice Address - Country:US
Practice Address - Phone:813-891-9943
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-07-27
Last Update Date:2009-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPT19558225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist