Provider Demographics
NPI:1154848034
Name:SHAW, ZACK (DPT)
Entity Type:Individual
Prefix:
First Name:ZACK
Middle Name:
Last Name:SHAW
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:725 MONTGOMERY LN
Mailing Address - Street 2:
Mailing Address - City:DECATUR
Mailing Address - State:IL
Mailing Address - Zip Code:62526-1268
Mailing Address - Country:US
Mailing Address - Phone:217-412-2302
Mailing Address - Fax:
Practice Address - Street 1:4855-57 EAST 36
Practice Address - Street 2:
Practice Address - City:DECATUR
Practice Address - State:IL
Practice Address - Zip Code:62521
Practice Address - Country:US
Practice Address - Phone:217-864-1264
Practice Address - Fax:217-864-1828
Is Sole Proprietor?:Yes
Enumeration Date:2017-08-23
Last Update Date:2019-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI14709225100000X
IL070023183225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty