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General NPI Number Information
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NPI Number | 1477807881
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Entity Type | Individual
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Provider Name | SUSAN IVERSON OTRL
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Gender | Female
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Dates
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Enumeration Date | 11/07/2012
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Last Update Date | 11/07/2012
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Provider Practice Location Address
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Address Line | 1582 ARBOR AVE
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City | HIGHLAND PARK
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State | IL
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Zip | 60035
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Country | US
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Telephone | 847-845-7206
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Fax |
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Provider Business Mailing Address
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Address Line | 1582 ARBOR AVE
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City | HIGHLAND PARK
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State | IL
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Zip | 60035-2767
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Country | US
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Telephone | 847-845-7206
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 314000000X
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Taxonomy Name | Skilled Nursing Facility
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License Number | 056000638
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License Number State | IL
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