Provider Demographics
NPI:1538471792
Name:DATE, REVATI MOHAN
Entity Type:Individual
Prefix:MISS
First Name:REVATI
Middle Name:MOHAN
Last Name:DATE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:525 W STRATFORD PL
Mailing Address - Street 2:APT # 280
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60657-2649
Mailing Address - Country:US
Mailing Address - Phone:412-867-1404
Mailing Address - Fax:
Practice Address - Street 1:525 W STRATFORD PL
Practice Address - Street 2:APT # 280
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60657-2649
Practice Address - Country:US
Practice Address - Phone:412-867-1404
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-07-05
Last Update Date:2010-07-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL056.009051225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist