Provider Demographics
NPI:1558411470
Name:DAVIES, STEPHANIE L (OTRL)
Entity Type:Individual
Prefix:MS
First Name:STEPHANIE
Middle Name:L
Last Name:DAVIES
Suffix:
Gender:F
Credentials:OTRL
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1100 W MONTROSE AVE
Mailing Address - Street 2:#504
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60613-5520
Mailing Address - Country:US
Mailing Address - Phone:773-477-7599
Mailing Address - Fax:773-477-7601
Practice Address - Street 1:1962 N BISSELL ST
Practice Address - Street 2:2 ND FLOOR
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60614-5015
Practice Address - Country:US
Practice Address - Phone:773-477-7599
Practice Address - Fax:773-477-7601
Is Sole Proprietor?:No
Enumeration Date:2007-01-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL056-003210225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID01635519OtherBCBS OF ILLINOIS