Healthcare Provider Details

I. General information

NPI: 1346067386
Provider Name (Legal Business Name): COURTNEY ANDERSON OTR/L
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/23/2024
Last Update Date: 08/30/2026
Certification Date: 08/30/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1749 S RANDALL RD STE A
GENEVA IL
60134-4616
US

IV. Provider business mailing address

9500 BORMET DR STE 304
MOKENA IL
60448-8399
US

V. Phone/Fax

Practice location:
  • Phone: 815-469-1500
  • Fax:
Mailing address:
  • Phone: 815-469-1500
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number8640-26
License Number StateWI
# 2
Primary TaxonomyY
Taxonomy Code225XP0200X
TaxonomyPediatric Occupational Therapist
License Number056.016382
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: