Provider Demographics
NPI:1194845511
Name:YUNDT, SHANNON J (PT)
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:J
Last Name:YUNDT
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:SHANNON
Other - Middle Name:J
Other - Last Name:CONDON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:790 REMINGTON BLVD
Mailing Address - Street 2:
Mailing Address - City:BOLINGBROOK
Mailing Address - State:IL
Mailing Address - Zip Code:60440-4909
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3082 CATON FARM RD
Practice Address - Street 2:
Practice Address - City:JOLIET
Practice Address - State:IL
Practice Address - Zip Code:60435-1455
Practice Address - Country:US
Practice Address - Phone:815-577-9936
Practice Address - Fax:815-577-9938
Is Sole Proprietor?:No
Enumeration Date:2007-03-30
Last Update Date:2015-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL070015633225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILP00931597OtherMEDICARE RAILROAD
ILP00438893Medicare PIN
IL202845155Medicare PIN
IL211082019Medicare PIN
ILP00931597OtherMEDICARE RAILROAD
ILF400201939Medicare UPIN