Healthcare Provider Details

I. General information

NPI: 1225959810
Provider Name (Legal Business Name): ALICIA MARIE ETHEN OTD, OTR/L
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/22/2026
Last Update Date: 07/22/2026
Certification Date: 07/21/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1371 ABBOTT CT
BUFFALO GROVE IL
60089-2367
US

IV. Provider business mailing address

1031 WHITEHALL DR
NORTHBROOK IL
60062-4659
US

V. Phone/Fax

Practice location:
  • Phone: 847-777-8995
  • Fax:
Mailing address:
  • Phone: 847-989-4639
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number056017098
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: