Healthcare Provider Details

I. General information

NPI: 1730227331
Provider Name (Legal Business Name): SANDRA JO FORTMANN M.S., OTRL
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/03/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1234 HUNTERS RDG E
HOFFMAN ESTATES IL
60192-4541
US

IV. Provider business mailing address

1234 HUNTERS RDG E
HOFFMAN ESTATES IL
60192-4541
US

V. Phone/Fax

Practice location:
  • Phone: 847-429-9615
  • Fax: 847-429-9615
Mailing address:
  • Phone: 847-429-9615
  • Fax: 847-429-9615

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225XP0200X
TaxonomyPediatric Occupational Therapist
License Number
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: