Healthcare Provider Details

I. General information

NPI: 1841530847
Provider Name (Legal Business Name): DAWN ENNIS WURST OTR/L
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/27/2013
Last Update Date: 02/05/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1308 WAUKEGAN RD
GLENVIEW IL
60025-3070
US

IV. Provider business mailing address

1358 W SUNNYSIDE AVE # 1
CHICAGO IL
60640-5583
US

V. Phone/Fax

Practice location:
  • Phone: 877-486-4140
  • Fax:
Mailing address:
  • Phone: 248-840-1105
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number056010041
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: