Provider Demographics
NPI:1093002578
Name:ANDERSON, OMESTRIS DION (OTR/L)
Entity Type:Individual
Prefix:MS
First Name:OMESTRIS
Middle Name:DION
Last Name:ANDERSON
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 1:22644 RIDGEWAY AVE
Mailing Address - Street 2:
Mailing Address - City:RICHTON PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60471-2514
Mailing Address - Country:US
Mailing Address - Phone:773-704-5671
Mailing Address - Fax:
Practice Address - Street 1:112 S HALSTED ST
Practice Address - Street 2:
Practice Address - City:CHICAGO HEIGHTS
Practice Address - State:IL
Practice Address - Zip Code:60411-1256
Practice Address - Country:US
Practice Address - Phone:708-756-1700
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-07-05
Last Update Date:2011-07-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL056006219171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator