Provider Demographics
NPI:1346001963
Name:BOLLHEIMER, SHAYNE J
Entity Type:Individual
Prefix:
First Name:SHAYNE
Middle Name:J
Last Name:BOLLHEIMER
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 1:49 WALNUT CIR
Mailing Address - Street 2:
Mailing Address - City:AVISTON
Mailing Address - State:IL
Mailing Address - Zip Code:62216-3537
Mailing Address - Country:US
Mailing Address - Phone:618-929-2709
Mailing Address - Fax:
Practice Address - Street 1:1022 E WESLEY DR
Practice Address - Street 2:
Practice Address - City:O FALLON
Practice Address - State:IL
Practice Address - Zip Code:62269-6107
Practice Address - Country:US
Practice Address - Phone:618-744-6613
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-01-22
Last Update Date:2024-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL160003017225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant