Healthcare Provider Details

I. General information

NPI: 1548822638
Provider Name (Legal Business Name): HEATHER RENE URBAN MSOT, OTR/L
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/28/2019
Last Update Date: 06/28/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7421 MADISON ST
FOREST PARK IL
60130-1575
US

IV. Provider business mailing address

100 FOREST PL APT P26
OAK PARK IL
60301-1113
US

V. Phone/Fax

Practice location:
  • Phone: 501-730-5012
  • Fax:
Mailing address:
  • Phone: 501-730-5012
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number056.013095
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: