Provider Demographics
NPI:1447464557
Name:BLUM, SHANNON LEIGH (ATC, PTA)
Entity type:Individual
Prefix:
First Name:SHANNON
Middle Name:LEIGH
Last Name:BLUM
Suffix:
Gender:F
Credentials:ATC, PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:647 SPIRIT AIRPARK WEST DR STE 101
Mailing Address - Street 2:
Mailing Address - City:CHESTERFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:63005-1032
Mailing Address - Country:US
Mailing Address - Phone:636-206-4225
Mailing Address - Fax:
Practice Address - Street 1:1120 W COMMERCE DR STE 100
Practice Address - Street 2:
Practice Address - City:FESTUS
Practice Address - State:MO
Practice Address - Zip Code:63028-2392
Practice Address - Country:US
Practice Address - Phone:636-224-7511
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-09
Last Update Date:2023-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO1139792255A2300X
MO2019027232225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer