Healthcare Provider Details

I. General information

NPI: 1376205807
Provider Name (Legal Business Name): KATELYN ANN MULDOON OTD, OTR/L
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/12/2021
Last Update Date: 01/26/2022
Certification Date: 01/19/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6501 S PROMONTORY DR # 1003
CHICAGO IL
60649-1002
US

IV. Provider business mailing address

6501 S PROMONTORY DR # 1003
CHICAGO IL
60649-1002
US

V. Phone/Fax

Practice location:
  • Phone: 773-363-6700
  • Fax:
Mailing address:
  • Phone: 773-363-6700
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225XP0200X
TaxonomyPediatric Occupational Therapist
License Number31007552A
License Number StateIN
# 2
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number056014684
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: