Provider Demographics
NPI:1982392056
Name:SHINE ON PEDIATRIC THERAPY, LLC
Entity Type:Organization
Organization Name:SHINE ON PEDIATRIC THERAPY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SPEECH-LANGUAGE PATHOLOGIST
Authorized Official - Prefix:MISS
Authorized Official - First Name:DIANA
Authorized Official - Middle Name:MARIA
Authorized Official - Last Name:VANSTEDUM
Authorized Official - Suffix:
Authorized Official - Credentials:MHS, CCC-SLP/L
Authorized Official - Phone:847-800-9530
Mailing Address - Street 1:21897 N INGLENOOK CT
Mailing Address - Street 2:
Mailing Address - City:DEER PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60010-9731
Mailing Address - Country:US
Mailing Address - Phone:847-800-9530
Mailing Address - Fax:
Practice Address - Street 1:21897 N INGLENOOK CT
Practice Address - Street 2:
Practice Address - City:DEER PARK
Practice Address - State:IL
Practice Address - Zip Code:60010-9731
Practice Address - Country:US
Practice Address - Phone:847-800-9530
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-04-26
Last Update Date:2023-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Single Specialty