Basic Information
| Provider Information | |||||||||
| NPI: | 1710965918 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | PEDIATRIC ADULT REHABILITATION ASSOCIATES | ||||||||
| LastName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | PARA'S PEACH TREE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 350 HOUBOLT RD | ||||||||
| Address2: | SUITE 101 | ||||||||
| City: | JOLIET | ||||||||
| State: | IL | ||||||||
| PostalCode: | 604318305 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8157259992 | ||||||||
| FaxNumber: | 8157259993 | ||||||||
| Practice Location | |||||||||
| Address1: | 350 HOUBOLT RD | ||||||||
| Address2: | SUITE 101 | ||||||||
| City: | JOLIET | ||||||||
| State: | IL | ||||||||
| PostalCode: | 604318305 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8157259992 | ||||||||
| FaxNumber: | 8157259993 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/06/2006 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | RUZICH | ||||||||
| AuthorizedOfficialFirstName: | SHAUNA | ||||||||
| AuthorizedOfficialMiddleName: | J | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT/CLINICAL MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 8157259992 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | MS CCC-SLP | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | X | 193200000X MULTI-SPECIALTY GROUP | Other Service Providers | Specialist | 225100000X | X | 193200000X MULTI-SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | 225700000X | X | 193200000X MULTI-SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Massage Therapist | 235Z00000X | 22003708A | IN | X | 193200000X MULTI-SPECIALTY GROUP | Speech, Language and Hearing Service Providers | Speech-Language Pathologist | 225X00000X | IL | X | 193200000X MULTI-SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist | 2355S0801X | IL | X | 193200000X MULTI-SPECIALTY GROUP | Speech, Language and Hearing Service Providers | Specialist/Technologist | Speech-Language Assistant | 235Z00000X | IL | X | 193200000X MULTI-SPECIALTY GROUP | Speech, Language and Hearing Service Providers | Speech-Language Pathologist |
ID Information
| ID | Type | State | Issuer | Description | 405254137001 | 05 | IL | MEDICAID |