Provider Demographics
NPI:1518132653
Name:SIPP, KRYSTAL LARAINA (COTA)
Entity Type:Individual
Prefix:MS
First Name:KRYSTAL
Middle Name:LARAINA
Last Name:SIPP
Suffix:
Gender:F
Credentials:COTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14226 S MICHIGAN AVE
Mailing Address - Street 2:
Mailing Address - City:RIVERDALE
Mailing Address - State:IL
Mailing Address - Zip Code:60827-2514
Mailing Address - Country:US
Mailing Address - Phone:773-298-1177
Mailing Address - Fax:773-298-0689
Practice Address - Street 1:14226 S MICHIGAN AVE
Practice Address - Street 2:
Practice Address - City:RIVERDALE
Practice Address - State:IL
Practice Address - Zip Code:60827-2514
Practice Address - Country:US
Practice Address - Phone:708-841-7995
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-04-29
Last Update Date:2008-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL057.001481224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant