Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 225X00000X | Occupational Therapist | 056002054 | IL |
N | 225XH1200X | Occupational Therapist - Hand | 056002054 | IL |
NPI | 1013900455 |
---|---|
Provider Name | Susan L Botica |
First Address | Bolingbrook, IL 60440-4909 |
Second Address | New Lenox, IL 60451-9712 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 30/08/2005 |
Last Update Date | 30/01/2012 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
670002092 | RAILROAD PROVIDER # (01) | IL |