Provider Demographics
NPI:1013154350
Name:STACHURA, SHANE T (PT, MPT)
Entity Type:Individual
Prefix:
First Name:SHANE
Middle Name:T
Last Name:STACHURA
Suffix:
Gender:M
Credentials:PT, MPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1120 N MELVIN ST
Mailing Address - Street 2:
Mailing Address - City:GIBSON CITY
Mailing Address - State:IL
Mailing Address - Zip Code:60936-1477
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:510 PRAIRIE LN
Practice Address - Street 2:
Practice Address - City:CISSNA PARK
Practice Address - State:IL
Practice Address - Zip Code:60924-9710
Practice Address - Country:US
Practice Address - Phone:815-457-2006
Practice Address - Fax:815-457-2016
Is Sole Proprietor?:No
Enumeration Date:2009-01-08
Last Update Date:2024-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist