Healthcare Provider Details

I. General information

NPI: 1699586719
Provider Name (Legal Business Name): SHANNON ELISE HERMAN PT, DPT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/17/2025
Last Update Date: 01/17/2025
Certification Date: 01/17/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

250 N LITCHFIELD RD STE 155
GOODYEAR AZ
85338-1367
US

IV. Provider business mailing address

5613 W ROUNDHOUSE RD
LAVEEN AZ
85339-1273
US

V. Phone/Fax

Practice location:
  • Phone: 623-882-9787
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberLPT-033913
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: