Healthcare Provider Details

I. General information

NPI: 1750680534
Provider Name (Legal Business Name): MELINDA LAUREEN SIMONSON OTR/L
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/20/2011
Last Update Date: 03/20/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

145 N MILWAUKEE AVE
VERNON HILLS IL
60061-4170
US

IV. Provider business mailing address

16 LONDONDERRY LN
LINCOLNSHIRE IL
60069-3900
US

V. Phone/Fax

Practice location:
  • Phone: 847-793-2470
  • Fax:
Mailing address:
  • Phone: 847-572-9423
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number056007451
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code225XG0600X
TaxonomyGerontology Occupational Therapist
License Number056007451
License Number StateIL
# 3
Primary TaxonomyN
Taxonomy Code225XL0004X
TaxonomyLow Vision Occupational Therapist
License Number056007451
License Number StateIL
# 4
Primary TaxonomyN
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number056007451
License Number StateIL
# 5
Primary TaxonomyN
Taxonomy Code320900000X
TaxonomyIntellectual and/or Developmental Disabilities Community Based Residential Treatment Facility
License Number056007451
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: