Provider Demographics
NPI:1639426075
Name:COTTON, GLEN S (OTD, OTR/L)
Entity Type:Individual
Prefix:DR
First Name:GLEN
Middle Name:S
Last Name:COTTON
Suffix:
Gender:M
Credentials:OTD, OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:823 W LAKESIDE PL
Mailing Address - Street 2:SUITE 3E
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60640-6768
Mailing Address - Country:US
Mailing Address - Phone:312-399-6764
Mailing Address - Fax:773-878-6507
Practice Address - Street 1:823 W LAKESIDE PL
Practice Address - Street 2:SUITE 3E
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60640-6768
Practice Address - Country:US
Practice Address - Phone:312-399-6764
Practice Address - Fax:773-878-6507
Is Sole Proprietor?:Yes
Enumeration Date:2012-08-03
Last Update Date:2013-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL056009471225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist