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General NPI Number Information
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NPI Number | 1922120591
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Entity Type | Individual
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Provider Name | SHYTAURA A GOSTON R.O.T,
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Gender | Female
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Dates
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Enumeration Date | 04/04/2007
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Last Update Date | 07/08/2007
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Provider Practice Location Address
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Address Line | 444 N WELLS ST STE 304
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City | CHICAGO
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State | IL
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Zip | 60610-4593
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Country | US
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Telephone | 312-494-9936
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Fax |
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Provider Business Mailing Address
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Address Line | 5333 S MICHIGAN AVE
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City | CHICAGO
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State | IL
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Zip | 60615-4604
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Country | US
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Telephone | 773-895-9738
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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 | 056005224
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License Number State | IL
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