Provider Demographics
NPI:1073769394
Name:BRATTSTROM BARRERA, CANDICE (OT)
Entity Type:Individual
Prefix:
First Name:CANDICE
Middle Name:
Last Name:BRATTSTROM BARRERA
Suffix:
Gender:F
Credentials:OT
Other - Prefix:
Other - First Name:CANDICE
Other - Middle Name:
Other - Last Name:BRATTSTROM
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OT
Mailing Address - Street 1:790 REMINGTON BLVD
Mailing Address - Street 2:
Mailing Address - City:BOLINGBROOK
Mailing Address - State:IL
Mailing Address - Zip Code:60440-4909
Mailing Address - Country:US
Mailing Address - Phone:630-296-2223
Mailing Address - Fax:
Practice Address - Street 1:18237 KEDZIE AVE
Practice Address - Street 2:
Practice Address - City:HOMEWOOD
Practice Address - State:IL
Practice Address - Zip Code:60430-1411
Practice Address - Country:US
Practice Address - Phone:708-957-1868
Practice Address - Fax:708-957-1925
Is Sole Proprietor?:No
Enumeration Date:2008-08-18
Last Update Date:2014-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL056001712225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILP00973809OtherMEDICARE RAILROAD
ILP00852538OtherMEDICARE RAILROAD
IL214692012Medicare PIN
ILF400123265Medicare PIN
IL216859074Medicare PIN