=====================================================
General NPI Number Information
=====================================================
NPI Number | 1568793875
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | SUPRIYA SEN OTR/L
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/26/2010
-----------------------------------------------------
Last Update Date | 01/26/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1740 W TAYLOR ST # MC814 C-100
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60612-7232
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 312-355-4390
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 221 E CULLERTON ST APT 701
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60616-1221
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 312-451-4390
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225XH1300X
-----------------------------------------------------
Taxonomy Name | Human Factors Occupational Therapist
-----------------------------------------------------
License Number | 056.004684
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------