Provider Demographics
NPI:1497345979
Name:KWON, LYDIA IKJAE (OTR)
Entity Type:Individual
Prefix:
First Name:LYDIA
Middle Name:IKJAE
Last Name:KWON
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 1:315 W TERRACE CT
Mailing Address - Street 2:
Mailing Address - City:PALATINE
Mailing Address - State:IL
Mailing Address - Zip Code:60067-6966
Mailing Address - Country:US
Mailing Address - Phone:847-445-4793
Mailing Address - Fax:
Practice Address - Street 1:315 W TERRACE CT
Practice Address - Street 2:
Practice Address - City:PALATINE
Practice Address - State:IL
Practice Address - Zip Code:60067-6966
Practice Address - Country:US
Practice Address - Phone:847-445-4793
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-01-19
Last Update Date:2021-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL056006234225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist