Provider Demographics
NPI:1558881912
Name:SHANA DIAMOND SLP
Entity Type:Organization
Organization Name:SHANA DIAMOND SLP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SPEECH-LANGUAGE PATHOLOGIST
Authorized Official - Prefix:
Authorized Official - First Name:SHANA
Authorized Official - Middle Name:I
Authorized Official - Last Name:DIAMOND
Authorized Official - Suffix:
Authorized Official - Credentials:MS CCC-SLP
Authorized Official - Phone:224-436-2508
Mailing Address - Street 1:1520 W SAND BAR CT UNIT 1A
Mailing Address - Street 2:
Mailing Address - City:ROUND LAKE BEACH
Mailing Address - State:IL
Mailing Address - Zip Code:60073-4657
Mailing Address - Country:US
Mailing Address - Phone:224-436-2508
Mailing Address - Fax:
Practice Address - Street 1:1520 W SAND BAR CT UNIT 1A
Practice Address - Street 2:
Practice Address - City:ROUND LAKE BEACH
Practice Address - State:IL
Practice Address - Zip Code:60073-4657
Practice Address - Country:US
Practice Address - Phone:224-436-2508
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-06-26
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL146013335235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL146013335OtherSPEECH-LANGUAGE PATHOLOGIST