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NPI Code Detail

MEDICARE: ILSE G GONGORA OTR/L

MEDICARE: ILSE G GONGORA 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
1225X00000XOccupational Therapist056.015867IL

General Provider Information

NPI Number : 1588425714
Entity Type Code : Individual
Provider Name (Legal Business Name) : ILSE G GONGORA OTR/L
Provider Business Mailing Address
First Line : 217 BERNICE AVE
Second Line :
City : NORTHLAKE
State : IL
Zip : 60164-1712
Country : US
Telephone Number :
Fax Number :
Provider Business Practice Location Address
First Line : 522 W CHESTNUT ST STE GA
Second Line :
City : HINSDALE
State : IL
Zip : 60521-3174
Country : US
Telephone Number : 331-271-5070
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 01/16/2024
Last Update Date : 01/16/2024

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Directions to “ ILSE G GONGORA OTR/L” Practice Location

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