Basic Information
| Provider Information | |||||||||
| NPI: | 1114003019 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ADCOCK | ||||||||
| FirstName: | SHANNON | ||||||||
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| Credential: | DPT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 18051 RIVER AVE | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | NOBLESVILLE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 460627091 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3177730002 | ||||||||
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| Practice Location | |||||||||
| Address1: | 18051 RIVER AVE | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | NOBLESVILLE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 460627091 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3177730002 | ||||||||
| FaxNumber: | 3177766095 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/31/2006 | ||||||||
| LastUpdateDate: | 04/21/2010 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 05008779 | IN | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | 200801180 | 05 | IN | MEDICAID |