Provider Demographics
NPI:1326147273
Name:SHANK, GRETCHEN L (PT)
Entity Type:Individual
Prefix:MS
First Name:GRETCHEN
Middle Name:L
Last Name:SHANK
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 1:3928 N PAULINA ST
Mailing Address - Street 2:APT 2
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60613-2518
Mailing Address - Country:US
Mailing Address - Phone:216-246-7103
Mailing Address - Fax:
Practice Address - Street 1:6500 W 65TH ST
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60638-4962
Practice Address - Country:US
Practice Address - Phone:708-496-1515
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-21
Last Update Date:2012-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH010500225100000X
IL070.016147225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0842995Medicaid
OH000000217473OtherANTHEMBLUECROSS/BLUESHIEL
OH366587Medicare PIN