Provider Demographics
NPI:1023243953
Name:MYATT, SHANE ADAM (LPT)
Entity type:Individual
Prefix:
First Name:SHANE
Middle Name:ADAM
Last Name:MYATT
Suffix:
Gender:M
Credentials:LPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:402 S JOHN REDDITT DR
Mailing Address - Street 2:
Mailing Address - City:LUFKIN
Mailing Address - State:TX
Mailing Address - Zip Code:75904-3107
Mailing Address - Country:US
Mailing Address - Phone:936-632-2107
Mailing Address - Fax:936-632-2108
Practice Address - Street 1:402 S JOHN REDDITT DR
Practice Address - Street 2:
Practice Address - City:LUFKIN
Practice Address - State:TX
Practice Address - Zip Code:75904-3107
Practice Address - Country:US
Practice Address - Phone:936-632-2107
Practice Address - Fax:936-632-2108
Is Sole Proprietor?:No
Enumeration Date:2009-05-21
Last Update Date:2010-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1135408225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist