Healthcare Provider Details

I. General information

NPI: 1306196654
Provider Name (Legal Business Name): SHIRLEY HYDE OTR
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/13/2012
Last Update Date: 09/13/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9912 S FOREST AVE
CHICAGO IL
60628-1440
US

IV. Provider business mailing address

3660 W 79TH AVE
MERRILLVILLE IN
46410-5004
US

V. Phone/Fax

Practice location:
  • Phone: 630-205-5006
  • Fax:
Mailing address:
  • Phone: 630-205-5006
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number056.003276
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: