Healthcare Provider Details

I. General information

NPI: 1104977263
Provider Name (Legal Business Name): GLORIA XIMENA GALLARDO O.T.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/16/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2930 S MICHIGAN AVE SUITE 107
CHICAGO IL
60616-3270
US

IV. Provider business mailing address

2537 W THOMAS ST FLOOR #1
CHICAGO IL
60622-3407
US

V. Phone/Fax

Practice location:
  • Phone: 312-842-3919
  • Fax: 312-842-3914
Mailing address:
  • Phone: 773-772-0909
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: