Provider Demographics
NPI:1235570953
Name:IBANEZ, ANDRES S (COTA)
Entity Type:Individual
Prefix:MR
First Name:ANDRES
Middle Name:S
Last Name:IBANEZ
Suffix:
Gender:M
Credentials:COTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1400 KIRK ST
Mailing Address - Street 2:
Mailing Address - City:EVANSTON
Mailing Address - State:IL
Mailing Address - Zip Code:60202-3218
Mailing Address - Country:US
Mailing Address - Phone:773-470-6464
Mailing Address - Fax:
Practice Address - Street 1:6840 W TOUHY AVE
Practice Address - Street 2:
Practice Address - City:NILES
Practice Address - State:IL
Practice Address - Zip Code:60714-4520
Practice Address - Country:US
Practice Address - Phone:773-470-6464
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-07-10
Last Update Date:2013-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL057.003404224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant