Healthcare Provider Details

I. General information

NPI: 1255965372
Provider Name (Legal Business Name): AMANDA J PERRY MOT, OTR/L
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/27/2020
Last Update Date: 06/24/2021
Certification Date: 06/07/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

738 ARMY TRAIL RD
CAROL STREAM IL
60188
US

IV. Provider business mailing address

2901 FINLEY RD STE 101
DOWNERS GROVE IL
60515-1394
US

V. Phone/Fax

Practice location:
  • Phone: 815-469-1500
  • Fax:
Mailing address:
  • Phone: 630-792-1800
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number056.013450
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: