=====================================================
General NPI Number Information
=====================================================
NPI Number | 1003616871
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | BETHANY LUNDEEN OTD
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/19/2025
-----------------------------------------------------
Last Update Date | 03/19/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1201 AMERICAN WAY
-----------------------------------------------------
City | LIBERTYVILLE
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60048-3935
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 254-733-5511
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2295 N SALEM LN
-----------------------------------------------------
City | ROUND LAKE BEACH
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60073-4944
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 254-733-5511
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225X00000X
-----------------------------------------------------
Taxonomy Name | Occupational Therapist
-----------------------------------------------------
License Number | 056016452
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------