Provider Demographics
NPI:1093808628
Name:NEDUMGOTTIL, MINI A (OTR/L)
Entity Type:Individual
Prefix:MISS
First Name:MINI
Middle Name:A
Last Name:NEDUMGOTTIL
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 1:362 FOSTER WAY
Mailing Address - Street 2:
Mailing Address - City:BOLINGBROOK
Mailing Address - State:IL
Mailing Address - Zip Code:60440
Mailing Address - Country:US
Mailing Address - Phone:708-202-8387
Mailing Address - Fax:
Practice Address - Street 1:5TH & ROOSEVELT RD
Practice Address - Street 2:
Practice Address - City:HINES
Practice Address - State:IL
Practice Address - Zip Code:60141
Practice Address - Country:US
Practice Address - Phone:708-202-8387
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL283X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes283X00000XHospitalsRehabilitation Hospital