Provider Demographics
NPI:1386229110
Name:FOLWARCZNY, TINA (COTA/L)
Entity Type:Individual
Prefix:
First Name:TINA
Middle Name:
Last Name:FOLWARCZNY
Suffix:
Gender:F
Credentials:COTA/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8117 N OCONTO AVE
Mailing Address - Street 2:
Mailing Address - City:NILES
Mailing Address - State:IL
Mailing Address - Zip Code:60714-3066
Mailing Address - Country:US
Mailing Address - Phone:773-320-9445
Mailing Address - Fax:
Practice Address - Street 1:8117 N OCONTO AVE
Practice Address - Street 2:
Practice Address - City:NILES
Practice Address - State:IL
Practice Address - Zip Code:60714-3066
Practice Address - Country:US
Practice Address - Phone:773-320-9445
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-03-12
Last Update Date:2021-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL057002057224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy AssistantGroup - Single Specialty