Provider Demographics
NPI:1396813309
Name:DIBIASE, SHEREE LYNN (PT)
Entity Type:Individual
Prefix:MS
First Name:SHEREE
Middle Name:LYNN
Last Name:DIBIASE
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 1:2170 W IRONWOOD CENTER DR
Mailing Address - Street 2:
Mailing Address - City:COEUR D ALENE
Mailing Address - State:ID
Mailing Address - Zip Code:83814-2606
Mailing Address - Country:US
Mailing Address - Phone:208-762-2100
Mailing Address - Fax:208-762-2101
Practice Address - Street 1:2170 W IRONWOOD CENTER DR
Practice Address - Street 2:
Practice Address - City:COEUR D ALENE
Practice Address - State:ID
Practice Address - Zip Code:83814-2606
Practice Address - Country:US
Practice Address - Phone:208-667-1988
Practice Address - Fax:208-765-5654
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-30
Last Update Date:2020-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDPT-6292251X0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID002734700Medicaid
WAAB33066Medicare PIN
ID1650828Medicare ID - Type Unspecified