Provider Demographics
NPI:1184861742
Name:DOUGLAS, SHANI M (PT, DPT)
Entity type:Individual
Prefix:
First Name:SHANI
Middle Name:M
Last Name:DOUGLAS
Suffix:
Gender:F
Credentials:PT, DPT
Other - Prefix:
Other - First Name:SHANI
Other - Middle Name:M
Other - Last Name:MCCLELLAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:10421 S WALLACE ST
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60628-2441
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:16651 HARLEM AVE
Practice Address - Street 2:
Practice Address - City:TINLEY PARK
Practice Address - State:IL
Practice Address - Zip Code:60477-2581
Practice Address - Country:US
Practice Address - Phone:708-444-2467
Practice Address - Fax:708-444-2758
Is Sole Proprietor?:No
Enumeration Date:2009-01-19
Last Update Date:2009-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL070-013962225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL214692006Medicare PIN