Provider Demographics
NPI:1578311411
Name:TRUESDALE, SHANNON NICOLE
Entity type:Individual
Prefix:
First Name:SHANNON
Middle Name:NICOLE
Last Name:TRUESDALE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15242 CENTRAL AVE
Mailing Address - Street 2:
Mailing Address - City:OAK FOREST
Mailing Address - State:IL
Mailing Address - Zip Code:60452-2121
Mailing Address - Country:US
Mailing Address - Phone:708-261-3355
Mailing Address - Fax:
Practice Address - Street 1:10501 EMILIE LN
Practice Address - Street 2:
Practice Address - City:ORLAND PARK
Practice Address - State:IL
Practice Address - Zip Code:60467-8872
Practice Address - Country:US
Practice Address - Phone:708-326-2300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-05-07
Last Update Date:2024-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL057004013224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant