Healthcare Provider Details

I. General information

NPI: 1053675280
Provider Name (Legal Business Name): AMY SHEVLIN PT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/03/2012
Last Update Date: 07/03/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2810 FRANK SCOTT PKWY W STE 824
BELLEVILLE IL
62223-5007
US

IV. Provider business mailing address

2810 FRANK SCOTT PKWY W STE 824
BELLEVILLE IL
62223-5007
US

V. Phone/Fax

Practice location:
  • Phone: 618-234-9705
  • Fax: 618-257-0665
Mailing address:
  • Phone: 618-234-9705
  • Fax: 618-257-0665

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number070010288
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: