Healthcare Provider Details

I. General information

NPI: 1043451495
Provider Name (Legal Business Name): SHANNON LUBS DPT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: SHANNON KRUGER

II. Dates (important events)

Enumeration Date: 03/16/2009
Last Update Date: 06/18/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1600 E BELTLINE AVE NE
GRAND RAPIDS MI
49525
US

IV. Provider business mailing address

600 OAKMONT LN STE 600C
WESTMONT IL
60559-5548
US

V. Phone/Fax

Practice location:
  • Phone: 616-818-0586
  • Fax: 616-818-0587
Mailing address:
  • Phone: 630-575-6200
  • Fax: 630-928-5080

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number070-016974
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number5501017661
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: