MEDICARE: SHANNON LISTEBARGER MPT

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225100000X	Physical Therapist	1169760	TX

General Provider Information

NPI Number	:	1972613248
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SHANNON LISTEBARGER MPT

Provider Business Mailing Address
First Line	:	6037 HARRIS PKWY
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76132-4103
Country	:	US
Telephone Number	:	817-370-9891
Fax Number	:	817-370-9894

Provider Business Practice Location Address
First Line	:	4625 BOAT CLUB RD
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76135-7022
Country	:	US
Telephone Number	:	817-238-9295
Fax Number	:	817-238-9299

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/30/2006
Last Update Date	:	07/08/2007

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