Provider Demographics
NPI:1922052877
Name:DEPAZ, SHANTIE J (OT)
Entity Type:Individual
Prefix:
First Name:SHANTIE
Middle Name:J
Last Name:DEPAZ
Suffix:
Gender:F
Credentials:OT
Other - Prefix:
Other - First Name:SHANTIE
Other - Middle Name:P
Other - Last Name:JABONERO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OT
Mailing Address - Street 1:27650 FERRY RD
Mailing Address - Street 2:SUITE 100
Mailing Address - City:WARRENVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:60555-3845
Mailing Address - Country:US
Mailing Address - Phone:630-225-2663
Mailing Address - Fax:630-225-2399
Practice Address - Street 1:27650 FERRY RD
Practice Address - Street 2:SUITE 100
Practice Address - City:WARRENVILLE
Practice Address - State:IL
Practice Address - Zip Code:60555-3845
Practice Address - Country:US
Practice Address - Phone:630-225-2663
Practice Address - Fax:630-225-2399
Is Sole Proprietor?:No
Enumeration Date:2006-05-22
Last Update Date:2014-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL056-005839225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILP01119017OtherRR MEDICARE
ILP01119017OtherRR MEDICARE