=====================================================
General NPI Number Information
=====================================================
NPI Number | 1528053055
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | SHONNA L FORTSCHNEIDER PT
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/12/2005
-----------------------------------------------------
Last Update Date | 11/01/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1719 CLAWSON ST
-----------------------------------------------------
City | ALTON
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 62002-4702
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 618-462-1133
-----------------------------------------------------
Fax | 618-462-3736
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 7339 WISE AVE
-----------------------------------------------------
City | SAINT LOUIS
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 63117-1718
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 314-485-7979
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225100000X
-----------------------------------------------------
Taxonomy Name | Physical Therapist
-----------------------------------------------------
License Number | 070011102
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------