Provider Demographics
NPI:1447586979
Name:PARDO, JUAN F (COTA/L)
Entity Type:Individual
Prefix:MR
First Name:JUAN
Middle Name:F
Last Name:PARDO
Suffix:
Gender:M
Credentials:COTA/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:113 PEBBLE BEACH DR
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:62704-3151
Mailing Address - Country:US
Mailing Address - Phone:217-787-3495
Mailing Address - Fax:
Practice Address - Street 1:444 W HARRISON AVE
Practice Address - Street 2:
Practice Address - City:DECATUR
Practice Address - State:IL
Practice Address - Zip Code:62526-4157
Practice Address - Country:US
Practice Address - Phone:217-877-7333
Practice Address - Fax:217-872-6723
Is Sole Proprietor?:Yes
Enumeration Date:2009-10-17
Last Update Date:2009-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL057000919224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant