Provider Demographics
NPI:1629695390
Name:DVORAK, KARIANNE DEBORAH
Entity Type:Individual
Prefix:
First Name:KARIANNE
Middle Name:DEBORAH
Last Name:DVORAK
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 1:9247 S MILLARD AVE
Mailing Address - Street 2:
Mailing Address - City:EVERGREEN PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60805-1407
Mailing Address - Country:US
Mailing Address - Phone:708-227-0615
Mailing Address - Fax:
Practice Address - Street 1:9247 S MILLARD AVE
Practice Address - Street 2:
Practice Address - City:EVERGREEN PARK
Practice Address - State:IL
Practice Address - Zip Code:60805-1407
Practice Address - Country:US
Practice Address - Phone:708-227-0615
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-06-29
Last Update Date:2020-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL056013566225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist