Provider Demographics
NPI:1073251740
Name:COSCOMB, BRITTNEY LYNN
Entity Type:Individual
Prefix:
First Name:BRITTNEY
Middle Name:LYNN
Last Name:COSCOMB
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4148 W CORNELIA AVE # 2
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60641-3918
Mailing Address - Country:US
Mailing Address - Phone:702-202-8079
Mailing Address - Fax:
Practice Address - Street 1:2437 N SOUTHPORT AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60614-2060
Practice Address - Country:US
Practice Address - Phone:773-472-8400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-05-23
Last Update Date:2022-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL056.014887225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist