MEDICARE: OT MAGIC INC.

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	252Y00000X	Early Intervention Provider Agency	VM736105001	IL

General Provider Information

NPI Number	:	1669790549
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	OT MAGIC INC.

Provider Business Mailing Address
First Line	:	1666 W 103RD ST
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60643-2819
Country	:	US
Telephone Number	:	773-510-7431
Fax Number	:	773-233-0756

Provider Business Practice Location Address
First Line	:	1666 W 103RD ST
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60643-2819
Country	:	US
Telephone Number	:	773-510-7431
Fax Number	:	773-233-0756

Authorized Official
Title or Position	:	PRESIDENT
Name	:	MRS. VALERIE MAXWELL-SOFIYEA
Credential	:	O.T.R.
Telephone Number	:	773-510-7431

Provider Enumeration Date	:	05/17/2010
Last Update Date	:	05/17/2010

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