Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 225X00000X | Occupational Therapist | 056-004549 | IL |
Y | 225XP0200X | Occupational Therapist - Pediatrics | 056-004549 | IL |
NPI | 1043315112 |
---|---|
Provider Name | Sarah Anne Mycek |
First Address | La Grange Park, IL 60526-1818 |
Second Address | La Grange Park, IL 60526-1818 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 14/09/2006 |
Last Update Date | 26/06/2019 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
01635996 | (02) | IL |
11543768 | (02) | IL |