Provider Demographics
NPI:1841310794
Name:SHADY-DAHL, DEBARA DIANE (DEVELOPMENTAL THERAP)
Entity type:Individual
Prefix:
First Name:DEBARA
Middle Name:DIANE
Last Name:SHADY-DAHL
Suffix:
Gender:F
Credentials:DEVELOPMENTAL THERAP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:109 LINDEN DR
Mailing Address - Street 2:
Mailing Address - City:COLONA
Mailing Address - State:IL
Mailing Address - Zip Code:61241-8807
Mailing Address - Country:US
Mailing Address - Phone:309-738-8969
Mailing Address - Fax:309-949-2135
Practice Address - Street 1:109 LINDEN DR
Practice Address - Street 2:
Practice Address - City:COLONA
Practice Address - State:IL
Practice Address - Zip Code:61241-8807
Practice Address - Country:US
Practice Address - Phone:309-738-8969
Practice Address - Fax:309-949-2135
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ILDS71511099P222Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL222Q00000XOtherDEVELOPMENTAL THERAPIST
IL222Q00000XOtherEVALUATOR