Basic Information
Provider Information | |||||||||
NPI: | 1942502950 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | TREADWELL | ||||||||
FirstName: | SHANNA | ||||||||
MiddleName: | L | ||||||||
NamePrefix: | MRS. | ||||||||
NameSuffix: |   | ||||||||
Credential: | PT | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | ANDREWS | ||||||||
OtherFirstName: | SHANNA | ||||||||
OtherMiddleName: | L | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | PT | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 346 GRAND AVE | ||||||||
Address2: |   | ||||||||
City: | JOHNSON CITY | ||||||||
State: | NY | ||||||||
PostalCode: | 137902580 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6077298156 | ||||||||
FaxNumber: | 6077293982 | ||||||||
Practice Location | |||||||||
Address1: | 91 CHENANGO BRIDGE RD | ||||||||
Address2: |   | ||||||||
City: | BINGHAMTON | ||||||||
State: | NY | ||||||||
PostalCode: | 139011293 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6076489292 | ||||||||
FaxNumber: | 6076487270 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 11/23/2010 | ||||||||
LastUpdateDate: | 12/08/2011 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 033404 | NY | Y |   | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |   | 225100000X | P78218 | NY | N |   | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |   |
ID Information
ID | Type | State | Issuer | Description | 03296820 | 05 | NY |   | MEDICAID |