Provider Demographics
NPI:1043315112
Name:MYCEK, SARAH ANNE (OTR/L)
Entity Type:Individual
Prefix:
First Name:SARAH
Middle Name:ANNE
Last Name:MYCEK
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:323 N STONE AVE
Mailing Address - Street 2:
Mailing Address - City:LA GRANGE PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60526-1818
Mailing Address - Country:US
Mailing Address - Phone:773-852-8720
Mailing Address - Fax:708-482-7432
Practice Address - Street 1:323 N STONE AVE
Practice Address - Street 2:
Practice Address - City:LA GRANGE PARK
Practice Address - State:IL
Practice Address - Zip Code:60526-1818
Practice Address - Country:US
Practice Address - Phone:773-852-8720
Practice Address - Fax:708-482-7432
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-14
Last Update Date:2019-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL056-004549225X00000X, 225XP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatrics
No225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL01635996Medicare UPIN
IL11543768Medicare UPIN