=====================================================
General NPI Number Information
=====================================================
NPI Number | 1609507318
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ANNA AGATA SEMANYSZYN
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/22/2022
-----------------------------------------------------
Last Update Date | 06/22/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 975 N 5TH AVE
-----------------------------------------------------
City | ST CHARLES
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60174-1299
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 630-443-8220
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1381 WINFIELD WAY
-----------------------------------------------------
City | ROSELLE
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60172-4750
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 847-337-3042
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 224Z00000X
-----------------------------------------------------
Taxonomy Name | Occupational Therapy Assistant
-----------------------------------------------------
License Number | 057.004546
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------