Healthcare Provider Details

I. General information

NPI: 1346433547
Provider Name (Legal Business Name): PEGGY OLOKO OT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/21/2007
Last Update Date: 08/21/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

16170 KINGSPORT RD
ORLAND PARK IL
60467-5602
US

IV. Provider business mailing address

6420 N WESTERN AVE
CHICAGO IL
60645-5422
US

V. Phone/Fax

Practice location:
  • Phone: 708-349-6544
  • Fax:
Mailing address:
  • Phone: 708-349-6544
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code224Z00000X
TaxonomyOccupational Therapy Assistant
License Number057001056
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: