Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 225X00000X | Occupational Therapist | 056014072 | IL |
NPI | 1003482985 |
---|---|
Provider Name | Kristen Martin |
First Address | Des Plaines, IL 60016-6574 |
Second Address | Lake Bluff, IL 60044-2235 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 01/06/2021 |
Last Update Date | 01/06/2021 |