Provider Demographics
NPI:1235648866
Name:SHAKE, BENNETT (DPT)
Entity type:Individual
Prefix:DR
First Name:BENNETT
Middle Name:
Last Name:SHAKE
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4082 WARTHOG HTS
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80916-3402
Mailing Address - Country:US
Mailing Address - Phone:214-232-2289
Mailing Address - Fax:
Practice Address - Street 1:4224 N NEVADA AVE STE 200
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80907-4368
Practice Address - Country:US
Practice Address - Phone:719-900-1817
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-09-27
Last Update Date:2024-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO0017676225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist