MEDICARE: SHANNON MICHELE DIPPOLD MPT

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225100000X	Physical Therapist	40QA01243700	NJ
2	225100000X	Physical Therapist	PT872592	DC
3	2251P0200X	Pediatric Physical Therapist	032014	NY
4	2251P0200X	Pediatric Physical Therapist	PT872592	DC

General Provider Information

NPI Number	:	1245567361
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SHANNON MICHELE DIPPOLD MPT

Provider Business Mailing Address
First Line	:	4827 30TH ST N
Second Line	:
City	:	ARLINGTON
State	:	VA
Zip	:	22207-2715
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1301 PENNSYLVANIA AVE SE
Second Line	:
City	:	WASHINGTON
State	:	DC
Zip	:	20003-3027
Country	:	US
Telephone Number	:	202-544-5439
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/10/2009
Last Update Date	:	08/24/2022

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