Healthcare Provider Details

I. General information

NPI: 1962098731
Provider Name (Legal Business Name): LAUREN SHIP OTR/L
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/16/2020
Last Update Date: 12/16/2020
Certification Date: 12/16/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1500 N CLYBOURN AVE UNIT C105
CHICAGO IL
60610-2295
US

IV. Provider business mailing address

2628 N BURLING ST APT 2
CHICAGO IL
60614-1514
US

V. Phone/Fax

Practice location:
  • Phone: 312-242-1665
  • Fax:
Mailing address:
  • Phone: 847-975-8859
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225XP0200X
TaxonomyPediatric Occupational Therapist
License Number056.013977
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: