Provider Demographics
NPI:1700143898
Name:BERTELS, SHANA B (COTA)
Entity Type:Individual
Prefix:
First Name:SHANA
Middle Name:B
Last Name:BERTELS
Suffix:
Gender:F
Credentials:COTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10354 PRAIRIE DELL RD
Mailing Address - Street 2:
Mailing Address - City:SHIPMAN
Mailing Address - State:IL
Mailing Address - Zip Code:62685-6105
Mailing Address - Country:US
Mailing Address - Phone:618-836-7442
Mailing Address - Fax:618-836-5487
Practice Address - Street 1:10354 PRAIRIE DELL RD
Practice Address - Street 2:
Practice Address - City:SHIPMAN
Practice Address - State:IL
Practice Address - Zip Code:62685-6105
Practice Address - Country:US
Practice Address - Phone:618-836-7442
Practice Address - Fax:618-836-5487
Is Sole Proprietor?:No
Enumeration Date:2012-04-13
Last Update Date:2012-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL057002709224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant