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? | Code | Type | Classification | Specialization | Group |
---|---|---|---|---|---|
Yes | 235Z00000X | Speech, Language and Hearing Service Providers | Speech-Language Pathologist | Group - Single Specialty |