Provider Demographics
NPI:1881735769
Name:PETERSON, SHAUNA (BS)
Entity type:Individual
Prefix:
First Name:SHAUNA
Middle Name:
Last Name:PETERSON
Suffix:
Gender:F
Credentials:BS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1820 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:ST CHARLES
Mailing Address - State:IL
Mailing Address - Zip Code:60174-1634
Mailing Address - Country:US
Mailing Address - Phone:630-762-1200
Mailing Address - Fax:630-762-1230
Practice Address - Street 1:1137 N EOLA RD
Practice Address - Street 2:SUITE 106
Practice Address - City:AURORA
Practice Address - State:IL
Practice Address - Zip Code:60502-7096
Practice Address - Country:US
Practice Address - Phone:630-236-6698
Practice Address - Fax:630-236-6856
Is Sole Proprietor?:No
Enumeration Date:2007-02-12
Last Update Date:2009-11-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL070008939225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist