MEDICARE: MISS SHANNA HADDOW DPT

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	050850	NY

General Provider Information

NPI Number	:	1659155810
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MISS SHANNA HADDOW DPT

Provider Business Mailing Address
First Line	:	191 PATCHOGUE YAPHANK RD
Second Line	:
City	:	EAST PATCHOGUE
State	:	NY
Zip	:	11772-4899
Country	:	US
Telephone Number	:	631-775-0971
Fax Number	:	631-475-0975

Provider Business Practice Location Address
First Line	:	159 ISLIP AVE
Second Line	:
City	:	ISLIP
State	:	NY
Zip	:	11751-3210
Country	:	US
Telephone Number	:	631-650-6347
Fax Number	:	631-650-6346

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

Provider Enumeration Date	:	08/21/2023
Last Update Date	:	08/21/2023

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