Provider Demographics
NPI:1649464736
Name:FADALE, SEAN (PT)
Entity type:Individual
Prefix:MR
First Name:SEAN
Middle Name:
Last Name:FADALE
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:611 W. PARK
Mailing Address - Street 2:
Mailing Address - City:RANTOUL
Mailing Address - State:IL
Mailing Address - Zip Code:61801-2500
Mailing Address - Country:US
Mailing Address - Phone:217-326-2911
Mailing Address - Fax:217-344-8047
Practice Address - Street 1:810 W ANTHONY DR
Practice Address - Street 2:
Practice Address - City:URBANA
Practice Address - State:IL
Practice Address - Zip Code:61802-7431
Practice Address - Country:US
Practice Address - Phone:217-326-1911
Practice Address - Fax:217-344-8047
Is Sole Proprietor?:No
Enumeration Date:2007-08-31
Last Update Date:2007-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL70014050225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL7216OtherPERSONALCARE PROVIDER #
IL203OtherBLUE CROSS PROVIDER #
IL113326OtherHEALTHLINK PROVIDER #
IL4117OtherHAMP PROVIDER #
IL203OtherBLUE CROSS PROVIDER #