MEDICARE: KRISTIN MARIE WALL OTR/L

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	056007919	IL

General Provider Information

NPI Number	:	1407107642
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KRISTIN MARIE WALL OTR/L

Provider Business Mailing Address
First Line	:	4646 N MARINE DR
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60640-5759
Country	:	US
Telephone Number	:	773-564-5748
Fax Number	:	773-564-5689

Provider Business Practice Location Address
First Line	:	4646 N MARINE DR
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60640-5759
Country	:	US
Telephone Number	:	773-564-5748
Fax Number	:	773-564-5689

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

Provider Enumeration Date	:	09/27/2012
Last Update Date	:	09/27/2012

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