MEDICARE: ROSE HEREDIA MS, 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		IL

General Provider Information

NPI Number	:	1740379924
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ROSE HEREDIA MS, OTR/L

Provider Business Mailing Address
First Line	:	9332 TRIPP AVE
Second Line	:
City	:	SKOKIE
State	:	IL
Zip	:	60076-1457
Country	:	US
Telephone Number	:	847-673-5421
Fax Number	:

Provider Business Practice Location Address
First Line	:	5225 OLD ORCHARD RD STE 18
Second Line	:
City	:	SKOKIE
State	:	IL
Zip	:	60077-1027
Country	:	US
Telephone Number	:	847-663-1020
Fax Number	:

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

Provider Enumeration Date	:	10/12/2006
Last Update Date	:	07/08/2007

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