Provider Demographics
NPI:1659514560
Name:FAJARDO, ANALIZA GAMBOA (OTR/L)
Entity Type:Individual
Prefix:
First Name:ANALIZA
Middle Name:GAMBOA
Last Name:FAJARDO
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1920 OLD SPRINGVILLE RD
Mailing Address - Street 2:SUITE 104
Mailing Address - City:BIRMINGHAM
Mailing Address - State:AL
Mailing Address - Zip Code:35215-5858
Mailing Address - Country:US
Mailing Address - Phone:205-572-0658
Mailing Address - Fax:
Practice Address - Street 1:505 COLLEGE AVE
Practice Address - Street 2:
Practice Address - City:OTTAWA
Practice Address - State:IL
Practice Address - Zip Code:61350-3865
Practice Address - Country:US
Practice Address - Phone:815-433-1130
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-04-08
Last Update Date:2009-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL056.008331225XG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XG0600XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGerontology