Healthcare Provider Details

I. General information

NPI: 1336129261
Provider Name (Legal Business Name): BRENDA MAE SHOUP PT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/18/2006
Last Update Date: 03/24/2026
Certification Date: 03/24/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

340 POLARIS PKWY
WESTERVILLE OH
43082-7971
US

IV. Provider business mailing address

340 POLARIS PKWY
WESTERVILLE OH
43082-7971
US

V. Phone/Fax

Practice location:
  • Phone: 614-839-2300
  • Fax: 614-839-2301
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPT008540
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code2251X0800X
TaxonomyOrthopedic Physical Therapist
License NumberPT08540
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: