MEDICARE: BRIANA MARIE CERTA OTD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225X00000X	Occupational Therapist	056.013690	IL

General Provider Information

NPI Number	:	1285244749
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	BRIANA MARIE CERTA OTD

Provider Business Mailing Address
First Line	:	2111 N KIMBALL AVE UNIT 1
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60647-3511
Country	:	US
Telephone Number	:	630-201-4714
Fax Number	:

Provider Business Practice Location Address
First Line	:	1190 OLD MCHENRY RD
Second Line	:
City	:	LONG GROVE
State	:	IL
Zip	:	60047-5088
Country	:	US
Telephone Number	:	847-613-4255
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/08/2020
Last Update Date	:	08/08/2020

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Directions to “ BRIANA MARIE CERTA OTD” Practice Location

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