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1023635364 NPI number — CRYSTAL MARY DIRKS COTA/L

NPI Number: 1023635364
Health Care Provider/Practitioner: CRYSTAL MARY DIRKS COTA/L

Information about “1023635364” NPI (CRYSTAL MARY DIRKS COTA/L) exists in 1023635364 in HTML format HTML  |  1023635364 in plain Text format TXT  |  1023635364 in PDF (Portable Document Format) PDF  |  1023635364 in an XML format XML  formats.

NPI Number : 1023635364 – JSON Data Format

                
{
  "Npi": {
    "NPI": "1023635364",
    "EntityType": "Individual",
    "ReplacementNPI": null,
    "EIN": null,
    "IsSoleProprietor": "N",
    "IsOrgSubpart": null,
    "ParentOrgLBN": null,
    "ParentOrgTIN": null,
    "OrgName": null,
    "LastName": "DIRKS",
    "FirstName": "CRYSTAL",
    "MiddleName": "MARY",
    "NamePrefix": "MRS.",
    "NameSuffix": null,
    "Credential": "COTA/L",
    "OtherOrgName": null,
    "OtherOrgNameTypeCode": null,
    "OtherLastName": "PEDZIEWIATR",
    "OtherFirstName": "CRYSTAL",
    "OtherMiddleName": "MARY",
    "OtherNamePrefix": "MISS",
    "OtherNameSuffix": null,
    "OtherCredential": "COTA/L",
    "OtherLastNameTypeCode": "1",
    "FirstLineMailingAddress": "1S221 EUCLID AVE",
    "SecondLineMailingAddress": null,
    "MailingAddressCityName": "VILLA PARK",
    "MailingAddressStateName": "IL",
    "MailingAddressPostalCode": "60181-3902",
    "MailingAddressCountryCode": "US",
    "MailingAddressTelephoneNumber": "630-995-0408",
    "MailingAddressFaxNumber": null,
    "FirstLinePracticeLocationAddress": "211 75TH ST",
    "SecondLinePracticeLocationAddress": null,
    "PracticeLocationAddressCityName": "BURR RIDGE",
    "PracticeLocationAddressStateName": "IL",
    "PracticeLocationAddressPostalCode": "60527",
    "PracticeLocationAddressCountryCode": "US",
    "PracticeLocationAddressTelephoneNumber": "630-230-1170",
    "PracticeLocationAddressFaxNumber": null,
    "EnumerationDate": "07/02/2020",
    "LastUpdateDate": "07/02/2020",
    "NPIDeactivationReasonCode": null,
    "NPIDeactivationReason": null,
    "NPIDeactivationDate": null,
    "NPIReactivationDate": null,
    "GenderCode": "F",
    "Gender": "Female",
    "AuthorizedOfficialLastName": null,
    "AuthorizedOfficialFirstName": null,
    "AuthorizedOfficialMiddleName": null,
    "AuthorizedOfficialTitle": null,
    "AuthorizedOfficialNamePrefix": null,
    "AuthorizedOfficialNameSuffix": null,
    "AuthorizedOfficialCredential": null,
    "AuthorizedOfficialTelephoneNumber": null,
    "Taxonomies": {
      "Taxonomy": {
        "TaxonomyCode": "224Z00000X",
        "TaxonomyName": "Occupational Therapy Assistant",
        "LicenseNumber": "057004588",
        "LicenseNumberStateCode": "IL",
        "PrimaryTaxonomySwitch": "Y"
      }
    },
    "HealthcareProviderTaxonomyGroups": null
  }
}
                
            

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