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General NPI Number Information
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NPI Number | 1851934921
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Entity Type | Individual
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Provider Name | COURTNEY GANSHO OTR/L
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Gender | Female
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Dates
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Enumeration Date | 10/22/2019
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Last Update Date | 10/22/2019
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Provider Practice Location Address
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Address Line | 350 W 154TH ST
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City | SOUTH HOLLAND
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State | IL
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Zip | 60473-1229
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Country | US
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Telephone | 708-333-7880
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Fax |
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Provider Business Mailing Address
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Address Line | 11367 LAVENDER LN
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City | FRANKFORT
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State | IL
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Zip | 60423-7849
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Country | US
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Telephone | 708-466-0063
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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 | 225X00000X
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Taxonomy Name | Occupational Therapist
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License Number | 393328
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License Number State |
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