Provider Demographics
NPI:1306403076
Name:CERNIVEC, MICHAEL (OTR/L)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:
Last Name:CERNIVEC
Suffix:
Gender:M
Credentials:OTR/L
Other - Prefix:
Other - First Name:MICHAEL
Other - Middle Name:
Other - Last Name:CERNIVEC
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:OTR/L
Mailing Address - Street 1:730 BEACON DR
Mailing Address - Street 2:
Mailing Address - City:LAKE BARRINGTON
Mailing Address - State:IL
Mailing Address - Zip Code:60010-1577
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1009 STATE ROUTE 22
Practice Address - Street 2:
Practice Address - City:FOX RIVER GROVE
Practice Address - State:IL
Practice Address - Zip Code:60021-1998
Practice Address - Country:US
Practice Address - Phone:847-462-8707
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-05-28
Last Update Date:2019-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL056.012880225XH1200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225XH1200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistHandGroup - Multi-Specialty