Healthcare Provider Details

I. General information

NPI: 1619702073
Provider Name (Legal Business Name): GRACE NICOLE SHUTZ
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/05/2024
Last Update Date: 09/05/2024
Certification Date: 09/05/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2346 MASCOUTAH AVE
BELLEVILLE IL
62220-3586
US

IV. Provider business mailing address

723 SHENANDOAH AVE
SAINT LOUIS MO
63104-4152
US

V. Phone/Fax

Practice location:
  • Phone: 618-277-6282
  • Fax:
Mailing address:
  • Phone: 773-225-8904
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number070.028593
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: