=====================================================
General NPI Number Information
=====================================================
NPI Number | 1689082638
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | SHANA M SEWICK MS, LAT, ATC
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/22/2014
-----------------------------------------------------
Last Update Date | 09/11/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2 E SOUTH ST
-----------------------------------------------------
City | GALESBURG
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 61401
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 309-341-7378
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1109 N CHERRY ST
-----------------------------------------------------
City | GALESBURG
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 61401-2739
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 815-997-3826
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 390200000X
-----------------------------------------------------
Taxonomy Name | Student in an Organized Health Care Education/Training Program
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------