Provider Demographics
NPI:1447833215
Name:BRAUER, SHANNON MAURA (PTA)
Entity type:Individual
Prefix:
First Name:SHANNON
Middle Name:MAURA
Last Name:BRAUER
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:113 W 10TH ST
Mailing Address - Street 2:
Mailing Address - City:COVINGTON
Mailing Address - State:KY
Mailing Address - Zip Code:41011-3016
Mailing Address - Country:US
Mailing Address - Phone:859-444-0590
Mailing Address - Fax:
Practice Address - Street 1:5467 CEDAR VILLAGE DR
Practice Address - Street 2:
Practice Address - City:MASON
Practice Address - State:OH
Practice Address - Zip Code:45040-8693
Practice Address - Country:US
Practice Address - Phone:859-444-0590
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-04-29
Last Update Date:2021-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH09120208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH113Medicaid