Basic Information
| Provider Information | |||||||||
| NPI: | 1386103125 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SHANN | ||||||||
| FirstName: | DORIAN | ||||||||
| MiddleName: | KIM | ||||||||
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| Credential: | DPT, CSCS | ||||||||
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| Mailing Information | |||||||||
| Address1: | 62 BEACON ST | ||||||||
| Address2: | |||||||||
| City: | BEACON | ||||||||
| State: | NY | ||||||||
| PostalCode: | 125082737 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8455546506 | ||||||||
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| Practice Location | |||||||||
| Address1: | 53 NY-17K SUITE 2 | ||||||||
| Address2: | |||||||||
| City: | NEWBURGH | ||||||||
| State: | NY | ||||||||
| PostalCode: | 12550 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8455612024 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 03/19/2019 | ||||||||
| LastUpdateDate: | 03/19/2019 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 044210 | NY | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | 044210 | 01 | NY | STATE LICENSE | OTHER |