Provider Demographics
NPI:1588325674
Name:WAID, SHAN EVE (PTA)
Entity type:Individual
Prefix:
First Name:SHAN
Middle Name:EVE
Last Name:WAID
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:676 COUNTY ROAD 650 N
Mailing Address - Street 2:
Mailing Address - City:SPARLAND
Mailing Address - State:IL
Mailing Address - Zip Code:61565-9657
Mailing Address - Country:US
Mailing Address - Phone:309-363-3061
Mailing Address - Fax:
Practice Address - Street 1:6901 N GALENA RD
Practice Address - Street 2:
Practice Address - City:PEORIA
Practice Address - State:IL
Practice Address - Zip Code:61614-3193
Practice Address - Country:US
Practice Address - Phone:309-692-4600
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-01-01
Last Update Date:2022-01-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL160009347225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant