Healthcare Provider Details

I. General information

NPI: 1053783142
Provider Name (Legal Business Name): ALEXANDER JAMES PORTER OTR/L
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/28/2015
Last Update Date: 10/28/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

66 MILLER DR SUITE 102
NORTH AURORA IL
60542-5143
US

IV. Provider business mailing address

66 MILLER DR SUITE 102
NORTH AURORA IL
60542-5143
US

V. Phone/Fax

Practice location:
  • Phone: 630-907-9165
  • Fax: 630-907-9195
Mailing address:
  • Phone: 630-907-9165
  • Fax: 630-907-9195

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225XP0200X
TaxonomyPediatric Occupational Therapist
License Number056.011260
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: