Healthcare Provider Details

I. General information

NPI: 1386458677
Provider Name (Legal Business Name): CORY ANDERSON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/05/2025
Last Update Date: 02/05/2025
Certification Date: 02/05/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1400 W GREENLEAF AVE
CHICAGO IL
60626-2805
US

IV. Provider business mailing address

1846 N CALIFORNIA AVE APT 2N
CHICAGO IL
60647-7414
US

V. Phone/Fax

Practice location:
  • Phone: 773-508-6100
  • Fax:
Mailing address:
  • Phone: 708-334-2876
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number056.014970
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: