MEDICARE: BHAVNA SHUKLA OTR

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225XP0200X	Pediatric Occupational Therapist		IL

General Provider Information

NPI Number	:	1003980087
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	BHAVNA SHUKLA OTR

Provider Business Mailing Address
First Line	:	856 W NELSON ST
Second Line	:	# 1106
City	:	CHICAGO
State	:	IL
Zip	:	60657-5152
Country	:	US
Telephone Number	:	773-746-2463
Fax Number	:

Provider Business Practice Location Address
First Line	:	856 W NELSON ST
Second Line	:	APT # 1106
City	:	CHICAGO
State	:	IL
Zip	:	60657-5152
Country	:	US
Telephone Number	:	773-746-2463
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/20/2006
Last Update Date	:	07/08/2007

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