Provider Demographics
NPI:1073947503
Name:ANDERSON, GLORIA DEAN (OT)
Entity Type:Individual
Prefix:MS
First Name:GLORIA
Middle Name:DEAN
Last Name:ANDERSON
Suffix:
Gender:F
Credentials:OT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5836 S. PRAIRIE AVE.
Mailing Address - Street 2:UNIT 2
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60637-4082
Mailing Address - Country:US
Mailing Address - Phone:773-426-5911
Mailing Address - Fax:
Practice Address - Street 1:222 S. RIVERSIDE PALAZA SUITE 830
Practice Address - Street 2:SUPPLEMENTAL HEALTH CARE
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60606
Practice Address - Country:US
Practice Address - Phone:312-416-3804
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-09-03
Last Update Date:2013-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL056.003668225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist