Provider Demographics
NPI:1114141405
Name:ROUNDTREE, DONNA YUDORA (OTR)
Entity Type:Individual
Prefix:
First Name:DONNA
Middle Name:YUDORA
Last Name:ROUNDTREE
Suffix:
Gender:F
Credentials:OTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16820 MANOR DR
Mailing Address - Street 2:
Mailing Address - City:SOUTH HOLLAND
Mailing Address - State:IL
Mailing Address - Zip Code:60473-4608
Mailing Address - Country:US
Mailing Address - Phone:708-474-6590
Mailing Address - Fax:708-474-6599
Practice Address - Street 1:16820 MANOR DR
Practice Address - Street 2:
Practice Address - City:SOUTH HOLLAND
Practice Address - State:IL
Practice Address - Zip Code:60473-4608
Practice Address - Country:US
Practice Address - Phone:708-474-6590
Practice Address - Fax:708-474-6599
Is Sole Proprietor?:No
Enumeration Date:2007-04-11
Last Update Date:2008-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL056002350225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL01635598OtherBLUE CROSS BLUE SHIELD