Provider Demographics
NPI:1255409934
Name:ARRIETA, SHANNON S (MPT)
Entity type:Individual
Prefix:MRS
First Name:SHANNON
Middle Name:S
Last Name:ARRIETA
Suffix:
Gender:F
Credentials:MPT
Other - Prefix:
Other - First Name:SHANNON
Other - Middle Name:S
Other - Last Name:FAIT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3601 30TH AVE STE 103
Mailing Address - Street 2:
Mailing Address - City:KENOSHA
Mailing Address - State:WI
Mailing Address - Zip Code:53144-1642
Mailing Address - Country:US
Mailing Address - Phone:262-657-0222
Mailing Address - Fax:262-657-7190
Practice Address - Street 1:1201 MAIN ST
Practice Address - Street 2:
Practice Address - City:UNION GROVE
Practice Address - State:WI
Practice Address - Zip Code:53182-1303
Practice Address - Country:US
Practice Address - Phone:262-878-9602
Practice Address - Fax:262-878-9609
Is Sole Proprietor?:No
Enumeration Date:2006-12-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI10635-024225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist