Provider Demographics
NPI:1154084390
Name:BURNS, BROOKE LYNN (MSOT R/L)
Entity Type:Individual
Prefix:
First Name:BROOKE
Middle Name:LYNN
Last Name:BURNS
Suffix:
Gender:F
Credentials:MSOT R/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16425 BORMET DR
Mailing Address - Street 2:
Mailing Address - City:TINLEY PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60477-8227
Mailing Address - Country:US
Mailing Address - Phone:708-262-8853
Mailing Address - Fax:
Practice Address - Street 1:17800 KEDZIE AVE
Practice Address - Street 2:
Practice Address - City:HAZEL CREST
Practice Address - State:IL
Practice Address - Zip Code:60429-2029
Practice Address - Country:US
Practice Address - Phone:708-799-8000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-10-14
Last Update Date:2021-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL056.014482225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILELT848366912OtherBLUE CROSS BLUE SHIELD