=====================================================
General NPI Number Information
=====================================================
NPI Number | 1124568258
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | KATLYN FISK OTD, OTR/L
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/08/2017
-----------------------------------------------------
Last Update Date | 03/08/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 345 E SUPERIOR ST
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60611-2654
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 815-245-6612
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2970 N SHERIDAN RD 1410
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60657-5864
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
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 | 056011637
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------