=====================================================
General NPI Number Information
=====================================================
NPI Number | 1659799724
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | KAREN PROSKUROVSKY MS, OTR/L
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/04/2014
-----------------------------------------------------
Last Update Date | 11/14/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2319 N ORCHARD ST CHN
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60614-3303
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 517-250-9045
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 832 W ALTGELD ST UNIT 1
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60614-2411
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 517-250-9045
-----------------------------------------------------
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 | 056.010849
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------