Provider Demographics
NPI:1609441294
Name:SHEPHERD, ELLEN BAILEY (OTD, OTR/L)
Entity Type:Individual
Prefix:DR
First Name:ELLEN
Middle Name:BAILEY
Last Name:SHEPHERD
Suffix:
Gender:F
Credentials:OTD, OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:225 N PARK ST
Mailing Address - Street 2:
Mailing Address - City:MANHATTAN
Mailing Address - State:IL
Mailing Address - Zip Code:60442-8142
Mailing Address - Country:US
Mailing Address - Phone:815-955-6576
Mailing Address - Fax:
Practice Address - Street 1:807 W JEFFERSON ST UNIT U
Practice Address - Street 2:
Practice Address - City:SHOREWOOD
Practice Address - State:IL
Practice Address - Zip Code:60404-7301
Practice Address - Country:US
Practice Address - Phone:814-714-2977
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-05-25
Last Update Date:2021-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL056.013699225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist