Healthcare Provider Details

I. General information

NPI: 1225850043
Provider Name (Legal Business Name): GRACE ANNE KUPCZYK
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/31/2024
Last Update Date: 11/06/2024
Certification Date: 11/06/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

17837 80TH AVE
TINLEY PARK IL
60477-5023
US

IV. Provider business mailing address

2122 YORK RD STE 300
OAK BROOK IL
60523-1925
US

V. Phone/Fax

Practice location:
  • Phone: 708-342-2500
  • Fax: 708-342-1454
Mailing address:
  • Phone: 630-575-1980
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number056016280
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: