Provider Demographics
NPI:1336168269
Name:SHAH, HETAL A (LPT)
Entity Type:Individual
Prefix:
First Name:HETAL
Middle Name:A
Last Name:SHAH
Suffix:
Gender:F
Credentials:LPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5220 S 6TH STREET RD
Mailing Address - Street 2:SUITE 1500
Mailing Address - City:SPRINGFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:62703-5735
Mailing Address - Country:US
Mailing Address - Phone:217-529-8469
Mailing Address - Fax:217-529-5580
Practice Address - Street 1:5220 S 6TH STREET RD
Practice Address - Street 2:SUITE 1500
Practice Address - City:SPRINGFIELD
Practice Address - State:IL
Practice Address - Zip Code:62703-5735
Practice Address - Country:US
Practice Address - Phone:217-529-8469
Practice Address - Fax:217-529-5580
Is Sole Proprietor?:No
Enumeration Date:2006-07-19
Last Update Date:2007-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist