Healthcare Provider Details

I. General information

NPI: 1619884632
Provider Name (Legal Business Name): MADISON KRISTINA LOLLI OTR/L
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/25/2026
Last Update Date: 08/25/2026
Certification Date: 08/25/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4619 N RAVENSWOOD AVE STE 300
CHICAGO IL
60640-4579
US

IV. Provider business mailing address

460 WENTWORTH CIR
CARY IL
60013-2321
US

V. Phone/Fax

Practice location:
  • Phone: 773-697-7333
  • Fax:
Mailing address:
  • Phone: 815-575-3977
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225XP0200X
TaxonomyPediatric Occupational Therapist
License Number056.027299
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: