Basic Information
| Provider Information | |||||||||
| NPI: | 1770034738 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SHANESY | ||||||||
| FirstName: | CHARLES | ||||||||
| MiddleName: | |||||||||
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| NameSuffix: | III | ||||||||
| Credential: | PT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 7591 TYLERS PLACE BLVD | ||||||||
| Address2: | |||||||||
| City: | WEST CHESTER | ||||||||
| State: | OH | ||||||||
| PostalCode: | 450696308 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5137556600 | ||||||||
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| Practice Location | |||||||||
| Address1: | 3817 COLONEL GLENN HWY | ||||||||
| Address2: | |||||||||
| City: | BEAVERCREEK | ||||||||
| State: | OH | ||||||||
| PostalCode: | 45324 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9374279200 | ||||||||
| FaxNumber: | 5137553762 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/14/2016 | ||||||||
| LastUpdateDate: | 08/22/2019 | ||||||||
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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 | 225X00000X | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist | 225100000X | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | AB7360731 | 01 | OH | MEDICARE PIN | OTHER | 2187155 | 05 | OH | MEDICAID |