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General NPI Number Information
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NPI Number | 1093205320
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Entity Type | Organization
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Legal Business Name | HEALTHPRO HERITAGE
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Dates
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Enumeration Date | 05/11/2018
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Last Update Date | 05/11/2018
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Provider Practice Location Address
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Address Line | 634 ACADEMY DR
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City | NORTHBROOK
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State | IL
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Zip | 60062-2421
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Country | US
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Telephone | 847-637-5151
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Fax |
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Provider Business Mailing Address
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Address Line | 6618 N SEELEY AVE
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City | CHICAGO
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State | IL
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Zip | 60645-5104
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Country | US
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Telephone | 773-398-1756
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Fax |
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Authorized Official
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Title or Position | OCCUPATIONAL THERAPIST
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Name | MEGHA P SHAH
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Credential | OTR/L
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Telephone | 773-398-1756
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 225X00000X
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Taxonomy Name | Occupational Therapist
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License Number | 056.012503
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License Number State | IL
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