Provider Demographics
NPI:1710965918
Name:PEDIATRIC ADULT REHABILITATION ASSOCIATES
Entity Type:Organization
Organization Name:PEDIATRIC ADULT REHABILITATION ASSOCIATES
Other - Org Name:PARA'S PEACH TREE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT/CLINICAL MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:SHAUNA
Authorized Official - Middle Name:J
Authorized Official - Last Name:RUZICH
Authorized Official - Suffix:
Authorized Official - Credentials:MS CCC-SLP
Authorized Official - Phone:815-725-9992
Mailing Address - Street 1:350 HOUBOLT RD
Mailing Address - Street 2:SUITE 101
Mailing Address - City:JOLIET
Mailing Address - State:IL
Mailing Address - Zip Code:60431-8305
Mailing Address - Country:US
Mailing Address - Phone:815-725-9992
Mailing Address - Fax:815-725-9993
Practice Address - Street 1:350 HOUBOLT RD
Practice Address - Street 2:SUITE 101
Practice Address - City:JOLIET
Practice Address - State:IL
Practice Address - Zip Code:60431-8305
Practice Address - Country:US
Practice Address - Phone:815-725-9992
Practice Address - Fax:815-725-9993
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-01-06
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
174400000X, 225100000X, 225700000X
IN22003708A235Z00000X
IL225X00000X, 2355S0801X, 235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Not Answered174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty
Not Answered225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty
Not Answered225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Multi-Specialty
Not Answered235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Multi-Specialty
Not Answered225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGroup - Multi-Specialty
Not Answered2355S0801XSpeech, Language and Hearing Service ProvidersSpecialist/TechnologistSpeech-Language AssistantGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL405254137001Medicaid