Provider Demographics
NPI:1114049111
Name:MALECHA, SHANE (PT, DPT, MS, CSCS)
Entity Type:Individual
Prefix:DR
First Name:SHANE
Middle Name:
Last Name:MALECHA
Suffix:
Gender:M
Credentials:PT, DPT, MS, CSCS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1514 SOMERSET DR
Mailing Address - Street 2:
Mailing Address - City:BEECHER
Mailing Address - State:IL
Mailing Address - Zip Code:60401-3436
Mailing Address - Country:US
Mailing Address - Phone:779-771-3322
Mailing Address - Fax:
Practice Address - Street 1:1514 SOMERSET DR
Practice Address - Street 2:
Practice Address - City:BEECHER
Practice Address - State:IL
Practice Address - Zip Code:60401-3436
Practice Address - Country:US
Practice Address - Phone:779-771-3322
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-03
Last Update Date:2020-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN7346225100000X
IL070.0155552251G0304X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251G0304XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGeriatrics
No225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL70015555OtherPHYSICAL THERAPY LICENSE
MN7346OtherPHYSICAL THERAPY LICENSE