Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 225XN1300X | Occupational Therapist - Neurorehabilitation | IL |
NPI | 1770167306 |
---|---|
Provider Name | Kelly Samson |
First Address | Grayslake, IL 60030-2026 |
Second Address | Grayslake, IL 60030-2026 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 10/05/2021 |
Last Update Date | 10/05/2021 |