=====================================================
General NPI Number Information
=====================================================
NPI Number | 1396235453
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | HEATHER LANDIS MS, OTR/L
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/15/2018
-----------------------------------------------------
Last Update Date | 04/24/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 21000 S FRANKFORT SQUARE RD UNIT D
-----------------------------------------------------
City | FRANKFORT
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60423-9385
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 815-469-1500
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 21000 S FRANKFORT SQUARE RD UNIT D
-----------------------------------------------------
City | FRANKFORT
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60423-9386
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225XP0200X
-----------------------------------------------------
Taxonomy Name | Pediatric Occupational Therapist
-----------------------------------------------------
License Number | 056.012522
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------