Provider Demographics
NPI:1235377912
Name:COSTANZO, SHEILA M (OTR/L)
Entity Type:Individual
Prefix:
First Name:SHEILA
Middle Name:M
Last Name:COSTANZO
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:SHEILA
Other - Middle Name:M
Other - Last Name:RAYMOND
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OTR/L
Mailing Address - Street 1:2830 W FITCH AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60645-2906
Mailing Address - Country:US
Mailing Address - Phone:773-595-5310
Mailing Address - Fax:
Practice Address - Street 1:2830 W FITCH AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60645-2906
Practice Address - Country:US
Practice Address - Phone:773-595-5310
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-02-03
Last Update Date:2010-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL056007832225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist