Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 225XG0600X | Occupational Therapist - Gerontology | 056012318 | IL |
NPI | 1942704598 |
---|---|
Provider Name | Kristin Hagen |
First Address | Northbrook, IL 60062-2421 |
Second Address | Northbrook, IL 60062-2421 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 20/03/2018 |
Last Update Date | 20/03/2018 |