Healthcare Provider Details

I. General information

NPI: 1740379924
Provider Name (Legal Business Name): ROSE HEREDIA MS, OTR/L
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/12/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5225 OLD ORCHARD RD STE 18
SKOKIE IL
60077-1027
US

IV. Provider business mailing address

9332 TRIPP AVE
SKOKIE IL
60076-1457
US

V. Phone/Fax

Practice location:
  • Phone: 847-663-1020
  • Fax:
Mailing address:
  • Phone: 847-673-5421
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: