Healthcare Provider Details

I. General information

NPI: 1316679327
Provider Name (Legal Business Name): DANIELA SAMANTHA SIROTT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/28/2022
Last Update Date: 07/26/2026
Certification Date: 07/26/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2255 N CAMPUS DRIVE
EVANSTON IL
60208-0001
US

IV. Provider business mailing address

1747 WINNETKA AVE
NORTHFIELD IL
60093-3318
US

V. Phone/Fax

Practice location:
  • Phone: 847-542-8833
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License NumberS630-1770-0736
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: