Basic Information
| Provider Information | |||||||||
| NPI: | 1255409934 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ARRIETA | ||||||||
| FirstName: | SHANNON | ||||||||
| MiddleName: | S. | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MPT | ||||||||
| OtherOrganizationName: | |||||||||
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| OtherLastName: | FAIT | ||||||||
| OtherFirstName: | SHANNON | ||||||||
| OtherMiddleName: | S. | ||||||||
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| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 3601 30TH AVE STE 103 | ||||||||
| Address2: | |||||||||
| City: | KENOSHA | ||||||||
| State: | WI | ||||||||
| PostalCode: | 531441642 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2626570222 | ||||||||
| FaxNumber: | 2626577190 | ||||||||
| Practice Location | |||||||||
| Address1: | 1201 MAIN ST | ||||||||
| Address2: | |||||||||
| City: | UNION GROVE | ||||||||
| State: | WI | ||||||||
| PostalCode: | 531821303 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2628789602 | ||||||||
| FaxNumber: | 2628789609 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/01/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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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 | 10635-024 | WI | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.