Provider Demographics
NPI:1568661833
Name:SCOTT, SHANA (MBA, LAT)
Entity Type:Individual
Prefix:
First Name:SHANA
Middle Name:
Last Name:SCOTT
Suffix:
Gender:F
Credentials:MBA, LAT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1442 HOMESTEAD RD
Mailing Address - Street 2:
Mailing Address - City:LA GRANGE PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60526-1167
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:711 W NORTH AVE
Practice Address - Street 2:SUITE 208
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60610-1174
Practice Address - Country:US
Practice Address - Phone:312-616-7778
Practice Address - Fax:312-276-4304
Is Sole Proprietor?:No
Enumeration Date:2007-07-16
Last Update Date:2014-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL096.0024302255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer