Provider Demographics
NPI:1043556756
Name:VASQUEZ, SHAWNA PENELOPE (OTR/L)
Entity Type:Individual
Prefix:MISS
First Name:SHAWNA
Middle Name:PENELOPE
Last Name:VASQUEZ
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1425 MACKINAC AVE
Mailing Address - Street 2:
Mailing Address - City:SOUTH MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53172-3043
Mailing Address - Country:US
Mailing Address - Phone:262-215-3279
Mailing Address - Fax:
Practice Address - Street 1:1425 MACKINAC AVE
Practice Address - Street 2:APT # 501
Practice Address - City:SOUTH MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53172
Practice Address - Country:US
Practice Address - Phone:262-215-3279
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-12-27
Last Update Date:2023-03-20
Deactivation Date:2023-02-06
Deactivation Code:
Reactivation Date:2023-03-20
Provider Licenses
StateLicense IDTaxonomies
WI5184-26225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist