Provider Demographics
NPI:1922764786
Name:DERIGER, SHANTILLE MARIE (OTR/L)
Entity Type:Individual
Prefix:MISS
First Name:SHANTILLE
Middle Name:MARIE
Last Name:DERIGER
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 1:549 CENTRE ST APT 4
Mailing Address - Street 2:
Mailing Address - City:NEWTON
Mailing Address - State:MA
Mailing Address - Zip Code:02458-2067
Mailing Address - Country:US
Mailing Address - Phone:951-212-1496
Mailing Address - Fax:
Practice Address - Street 1:179 BEAR HILL RD
Practice Address - Street 2:
Practice Address - City:WALTHAM
Practice Address - State:MA
Practice Address - Zip Code:02451-1063
Practice Address - Country:US
Practice Address - Phone:781-895-9500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-11-16
Last Update Date:2021-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA13454225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist