Healthcare Provider Details

I. General information

NPI: 1043315112
Provider Name (Legal Business Name): SARAH ANNE MYCEK OTR/L
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/14/2006
Last Update Date: 06/26/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

323 N STONE AVE
LA GRANGE PARK IL
60526-1818
US

IV. Provider business mailing address

323 N STONE AVE
LA GRANGE PARK IL
60526-1818
US

V. Phone/Fax

Practice location:
  • Phone: 773-852-8720
  • Fax: 708-482-7432
Mailing address:
  • Phone: 773-852-8720
  • Fax: 708-482-7432

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number056-004549
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code225XP0200X
TaxonomyPediatric Occupational Therapist
License Number056-004549
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: