Provider Demographics
NPI:1073832010
Name:SHEA, KATHLEEN A
Entity Type:Individual
Prefix:MRS
First Name:KATHLEEN
Middle Name:A
Last Name:SHEA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:508 E SCOVILL ST
Mailing Address - Street 2:
Mailing Address - City:URBANA
Mailing Address - State:IL
Mailing Address - Zip Code:61801-6745
Mailing Address - Country:US
Mailing Address - Phone:217-344-3903
Mailing Address - Fax:
Practice Address - Street 1:508 E SCOVILL ST
Practice Address - Street 2:
Practice Address - City:URBANA
Practice Address - State:IL
Practice Address - Zip Code:61801-6745
Practice Address - Country:US
Practice Address - Phone:217-344-3903
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-05-28
Last Update Date:2010-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL222Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist