Healthcare Provider Details

I. General information

NPI: 1205749546
Provider Name (Legal Business Name): GEMMA CLARE BROUDER MOT, OTR/L
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/28/2026
Last Update Date: 10/08/2026
Certification Date: 10/08/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10201 S CICERO AVE STE F
OAK LAWN IL
60453-4098
US

IV. Provider business mailing address

9500 BORMET DR STE 304
MOKENA IL
60448-8399
US

V. Phone/Fax

Practice location:
  • Phone: 708-332-8735
  • Fax:
Mailing address:
  • Phone: 815-469-1500
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number056.027401
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: