Provider Demographics
NPI:1205317567
Name:BANZUELA, THERESA (COTA/L)
Entity type:Individual
Prefix:
First Name:THERESA
Middle Name:
Last Name:BANZUELA
Suffix:
Gender:F
Credentials:COTA/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5320 W FLETCHER ST
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60641-4944
Mailing Address - Country:US
Mailing Address - Phone:773-971-3352
Mailing Address - Fax:
Practice Address - Street 1:5320 W FLETCHER ST
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60641-4944
Practice Address - Country:US
Practice Address - Phone:773-971-3352
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-08-24
Last Update Date:2018-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL057.004963224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant