Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 225100000X | Physical Therapist | 7346 | MN |
Y | 2251G0304X | Physical Therapist - Geriatrics | 070.015555 | IL |
NPI | 1114049111 |
---|---|
Provider Name | Dr. Shane Malecha |
First Address | Beecher, IL 60401-3436 |
Second Address | Beecher, IL 60401-3436 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 03/04/2007 |
Last Update Date | 06/08/2020 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
70015555 | PHYSICAL THERAPY LICENSE (01) | IL |
7346 | PHYSICAL THERAPY LICENSE (01) | MN |