Provider Demographics
NPI:1447322664
Name:SHAFER, PERI PAIGE (OTRL)
Entity type:Individual
Prefix:
First Name:PERI PAIGE
Middle Name:
Last Name:SHAFER
Suffix:
Gender:F
Credentials:OTRL
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9950 HAMLIN BLVD
Mailing Address - Street 2:APT 305
Mailing Address - City:SEMINOLE
Mailing Address - State:FL
Mailing Address - Zip Code:33776-1063
Mailing Address - Country:US
Mailing Address - Phone:773-750-0287
Mailing Address - Fax:
Practice Address - Street 1:9950 HAMLIN BLVD APT 305
Practice Address - Street 2:
Practice Address - City:SEMINOLE
Practice Address - State:FL
Practice Address - Zip Code:33776-1038
Practice Address - Country:US
Practice Address - Phone:773-750-0287
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-14
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL16909225X00000X
IN31003930A225X00000X
IL056006458225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL1619980OtherBCBS OF IL
ILK49988Medicare PIN
IL600000001Medicare PIN
IL1619980OtherBCBS OF IL
IL600000Medicare PIN
ILL95305Medicare PIN
IL600040Medicare PIN