Healthcare Provider Details

I. General information

NPI: 1417081613
Provider Name (Legal Business Name): MARIA VERONICA LLERENA OT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/16/2007
Last Update Date: 05/20/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1620 N LA SALLE DR
CHICAGO IL
60614-6005
US

IV. Provider business mailing address

5918 W DAKIN ST
CHICAGO IL
60634-2640
US

V. Phone/Fax

Practice location:
  • Phone: 312-943-3600
  • Fax:
Mailing address:
  • Phone: 312-342-1773
  • Fax: 773-439-2814

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225XP0200X
TaxonomyPediatric Occupational Therapist
License Number56006074
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: