Basic Information
| Provider Information | |||||||||
| NPI: | 1215422837 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | LISTON | ||||||||
| FirstName: | SHANE | ||||||||
| MiddleName: | M | ||||||||
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| Credential: | MOT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2122 YORK RD STE 300 | ||||||||
| Address2: | |||||||||
| City: | OAK BROOK | ||||||||
| State: | IL | ||||||||
| PostalCode: | 605231925 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6305751980 | ||||||||
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| Practice Location | |||||||||
| Address1: | 2272 95TH ST STE 300 | ||||||||
| Address2: | |||||||||
| City: | NAPERVILLE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 605648952 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6304281503 | ||||||||
| FaxNumber: | 6304281542 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/26/2018 | ||||||||
| LastUpdateDate: | 02/08/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 02/08/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225X00000X | 056012548 | IL | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist |
No ID Information.