MEDICARE: CHANON VALLAS OT

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	225XH1200X	Hand Occupational Therapist	8681	MA
2	225X00000X	Occupational Therapist

General Provider Information

NPI Number	:	1457524316
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CHANON VALLAS OT

Provider Business Mailing Address
First Line	:	790 REMINGTON BLVD
Second Line	:
City	:	BOLINGBROOK
State	:	IL
Zip	:	60440-4909
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	300 BIRNIE AVE STE 304
Second Line	:
City	:	SPRINGFIELD
State	:	MA
Zip	:	01107-1121
Country	:	US
Telephone Number	:	413-781-1054
Fax Number	:

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

Provider Enumeration Date	:	04/10/2008
Last Update Date	:	12/12/2023

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Directions to “ CHANON VALLAS OT” Practice Location

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