Healthcare Provider Details

I. General information

NPI: 1437409091
Provider Name (Legal Business Name): SHANNON MARIE KASPEREK DPT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: SHANNON MARIE BOHEN DPT

II. Dates (important events)

Enumeration Date: 09/11/2012
Last Update Date: 03/12/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10714 NORTH RD
PERRYSBURG NY
14129-9746
US

IV. Provider business mailing address

10714 NORTH RD
PERRYSBURG NY
14129-9746
US

V. Phone/Fax

Practice location:
  • Phone: 716-532-1049
  • Fax:
Mailing address:
  • Phone: 716-532-1049
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number033931-1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: