Provider Demographics
NPI:1740379924
Name:HEREDIA, ROSE (MS, OTR/L)
Entity Type:Individual
Prefix:
First Name:ROSE
Middle Name:
Last Name:HEREDIA
Suffix:
Gender:F
Credentials:MS, OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9332 TRIPP AVE
Mailing Address - Street 2:
Mailing Address - City:SKOKIE
Mailing Address - State:IL
Mailing Address - Zip Code:60076-1457
Mailing Address - Country:US
Mailing Address - Phone:847-673-5421
Mailing Address - Fax:
Practice Address - Street 1:5225 OLD ORCHARD RD STE 18
Practice Address - Street 2:
Practice Address - City:SKOKIE
Practice Address - State:IL
Practice Address - Zip Code:60077-1027
Practice Address - Country:US
Practice Address - Phone:847-663-1020
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist