=====================================================
General NPI Number Information
=====================================================
NPI Number | 1215109558
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | SIR GEORGE D WASHINGTON OT
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/27/2008
-----------------------------------------------------
Last Update Date | 05/23/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3309 CUMBERLAND TRL
-----------------------------------------------------
City | OLYMPIA FIELDS
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60461-1120
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 708-359-2670
-----------------------------------------------------
Fax | 708-274-1979
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3309 CUMBERLAND TRL
-----------------------------------------------------
City | OLYMPIA FIELDS
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60461-1120
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 708-359-2670
-----------------------------------------------------
Fax | 708-274-1979
-----------------------------------------------------
=====================================================
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 | 056007539
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------