=====================================================
General NPI Number Information
=====================================================
NPI Number | 1578091609
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | AMY MARIE RODER OTR/L
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/02/2017
-----------------------------------------------------
Last Update Date | 06/02/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 355 E ERIE ST
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60611-3167
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 312-238-1000
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4608 N LONG AVE APT 2
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60630-3516
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 773-398-2909
-----------------------------------------------------
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 | 056010606
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------