Healthcare Provider Details

I. General information

NPI: 1235403577
Provider Name (Legal Business Name): TEDDY HSU OT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/05/2012
Last Update Date: 03/05/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

909 DAVIS ST STE 220
EVANSTON IL
60201-3683
US

IV. Provider business mailing address

909 DAVIS ST STE 220
EVANSTON IL
60201-3683
US

V. Phone/Fax

Practice location:
  • Phone: 847-733-7906
  • Fax: 847-733-8405
Mailing address:
  • Phone: 847-733-7906
  • Fax: 847-733-8405

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number056-009655
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: