Healthcare Provider Details

I. General information

NPI: 1467531202
Provider Name (Legal Business Name): SHANNON BULLOCK MILLINER MPT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/03/2006
Last Update Date: 01/13/2020
Certification Date: 01/13/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

982 EASTERN PKWY
LOUISVILLE KY
40217-1566
US

IV. Provider business mailing address

7506 WARRENTON HILL CT
LOUISVILLE KY
40291-6716
US

V. Phone/Fax

Practice location:
  • Phone: 502-635-6397
  • Fax:
Mailing address:
  • Phone: 502-262-5710
  • Fax: 502-762-9250

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number004010
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: