Provider Demographics
NPI:1235554486
Name:DE ROSAS, BRYAN (OTR/L)
Entity Type:Individual
Prefix:MR
First Name:BRYAN
Middle Name:
Last Name:DE ROSAS
Suffix:
Gender:M
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 1:4828 N NOTTINGHAM AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60656-3825
Mailing Address - Country:US
Mailing Address - Phone:312-420-9354
Mailing Address - Fax:
Practice Address - Street 1:5130 W JACKSON BLVD
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60644-4332
Practice Address - Country:US
Practice Address - Phone:773-921-8000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-02-25
Last Update Date:2014-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL056.005948225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist