=====================================================
General NPI Number Information
=====================================================
NPI Number | 1033775580
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | LEEANN MARIE SHOLL LMT, PTA
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/09/2019
-----------------------------------------------------
Last Update Date | 06/08/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 224 LIBERTY ST UNIT A
-----------------------------------------------------
City | WARREN
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 16365-2344
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 814-230-5909
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2 CUTTING ST
-----------------------------------------------------
City | JAMESTOWN
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 14701-7217
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 716-489-1233
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225200000X
-----------------------------------------------------
Taxonomy Name | Physical Therapy Assistant
-----------------------------------------------------
License Number | 010794-1
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 225200000X
-----------------------------------------------------
Taxonomy Name | Physical Therapy Assistant
-----------------------------------------------------
License Number | TEI004449
-----------------------------------------------------
License Number State | PA
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 225700000X
-----------------------------------------------------
Taxonomy Name | Massage Therapist
-----------------------------------------------------
License Number | MSG012750
-----------------------------------------------------
License Number State | PA
-----------------------------------------------------