Provider Demographics
NPI:1639456890
Name:CHAN, RAILI (OT)
Entity Type:Individual
Prefix:
First Name:RAILI
Middle Name:
Last Name:CHAN
Suffix:
Gender:F
Credentials:OT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3053 S THROOP ST
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60608-5812
Mailing Address - Country:US
Mailing Address - Phone:773-557-9670
Mailing Address - Fax:
Practice Address - Street 1:975 E NERGE RD
Practice Address - Street 2:SUITE N-140
Practice Address - City:ROSELLE
Practice Address - State:IL
Practice Address - Zip Code:60172-4804
Practice Address - Country:US
Practice Address - Phone:874-437-9889
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-11-15
Last Update Date:2011-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL056.009543225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist