Provider Demographics
NPI:1689147720
Name:WELCH, SHAYNE BARBARA (PT)
Entity type:Individual
Prefix:MRS
First Name:SHAYNE
Middle Name:BARBARA
Last Name:WELCH
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:639 LINCOLN AVE
Mailing Address - Street 2:
Mailing Address - City:WINNETKA
Mailing Address - State:IL
Mailing Address - Zip Code:60093-2345
Mailing Address - Country:US
Mailing Address - Phone:312-286-1506
Mailing Address - Fax:
Practice Address - Street 1:40 SKOKIE BLVD STE 110
Practice Address - Street 2:
Practice Address - City:NORTHBROOK
Practice Address - State:IL
Practice Address - Zip Code:60062-1614
Practice Address - Country:US
Practice Address - Phone:224-407-4400
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-01-10
Last Update Date:2019-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL070011992225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist