Healthcare Provider Details

I. General information

NPI: 1720884992
Provider Name (Legal Business Name): SHANA MANGALDAS OTR/L, CLT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/19/2025
Last Update Date: 02/20/2025
Certification Date: 02/20/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4721 N CLARK ST STE 1S
CHICAGO IL
60640-7553
US

IV. Provider business mailing address

8202 CHESTERTON DR
WOODRIDGE IL
60517-8027
US

V. Phone/Fax

Practice location:
  • Phone: 773-770-3682
  • Fax:
Mailing address:
  • Phone: 832-544-0006
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225XE1200X
TaxonomyErgonomics Occupational Therapist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code225XH1200X
TaxonomyHand Occupational Therapist
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code225XN1300X
TaxonomyNeurorehabilitation Occupational Therapist
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number056.013933
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: