Healthcare Provider Details

I. General information

NPI: 1578500211
Provider Name (Legal Business Name): RUSSELL HOLLANDER OT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/01/2006
Last Update Date: 12/18/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4501 N WINCHESTER AVE 3RD FL
CHICAGO IL
60640
US

IV. Provider business mailing address

4501 N WINCHESTER AVE 3RD FL
CHICAGO IL
60640
US

V. Phone/Fax

Practice location:
  • Phone: 773-250-0500
  • Fax: 773-250-0497
Mailing address:
  • Phone: 773-250-0500
  • Fax: 773-250-0497

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number056000818
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: