Provider Demographics
NPI:1063275279
Name:WILSON, SHAWNECE LASHAY (COTA/L)
Entity type:Individual
Prefix:
First Name:SHAWNECE
Middle Name:LASHAY
Last Name:WILSON
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 1:10520 S PEORIA ST
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60643-3026
Mailing Address - Country:US
Mailing Address - Phone:773-226-1712
Mailing Address - Fax:
Practice Address - Street 1:10632 BLUE HERON DR
Practice Address - Street 2:
Practice Address - City:ORLAND PARK
Practice Address - State:IL
Practice Address - Zip Code:60467-5489
Practice Address - Country:US
Practice Address - Phone:708-910-8272
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-01-31
Last Update Date:2024-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL057.005295224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant