Healthcare Provider Details

I. General information

NPI: 1497819080
Provider Name (Legal Business Name): AMY P URBAN OTRL
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/20/2006
Last Update Date: 01/11/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

17929 GOTTSCHALK AVE
HOMEWOOD IL
60430-1709
US

IV. Provider business mailing address

1450 MONICA LN
NEW LENOX IL
60451-3076
US

V. Phone/Fax

Practice location:
  • Phone: 708-206-6155
  • Fax: 708-206-6159
Mailing address:
  • Phone: 708-359-6141
  • Fax: 815-280-0732

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number056-005079
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: