Provider Demographics
NPI:1518741073
Name:O'BRENNAN, SHANE
Entity type:Individual
Prefix:
First Name:SHANE
Middle Name:
Last Name:O'BRENNAN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2001 BUTTERFIELD RD STE 1600
Mailing Address - Street 2:
Mailing Address - City:DOWNERS GROVE
Mailing Address - State:IL
Mailing Address - Zip Code:60515-1211
Mailing Address - Country:US
Mailing Address - Phone:866-370-8206
Mailing Address - Fax:
Practice Address - Street 1:4411 SAN MATEO BLVD NE STE 11
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87109-2011
Practice Address - Country:US
Practice Address - Phone:515-217-3907
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-08-24
Last Update Date:2025-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
225100000X
SC225100000X
NMPT20250217225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist