Provider Demographics
NPI:1063835551
Name:MICEK, JUDITH (MOT/L,CHT)
Entity Type:Individual
Prefix:
First Name:JUDITH
Middle Name:
Last Name:MICEK
Suffix:
Gender:F
Credentials:MOT/L,CHT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:600 OAKMONT LN STE 600C
Mailing Address - Street 2:
Mailing Address - City:WESTMONT
Mailing Address - State:IL
Mailing Address - Zip Code:60559-5548
Mailing Address - Country:US
Mailing Address - Phone:660-575-6200
Mailing Address - Fax:
Practice Address - Street 1:1256 W BOUGHTON RD
Practice Address - Street 2:
Practice Address - City:BOLINGBROOK
Practice Address - State:IL
Practice Address - Zip Code:60440-6568
Practice Address - Country:US
Practice Address - Phone:630-378-9420
Practice Address - Fax:630-378-9169
Is Sole Proprietor?:No
Enumeration Date:2014-02-04
Last Update Date:2018-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL056-000410225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist