Provider Demographics
NPI:1780865063
Name:GRACE, INGRID ANDERSON (OT)
Entity Type:Individual
Prefix:
First Name:INGRID
Middle Name:ANDERSON
Last Name:GRACE
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 1:1268 SHERIDAN RD
Mailing Address - Street 2:
Mailing Address - City:HIGHLAND PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60035-4120
Mailing Address - Country:US
Mailing Address - Phone:847-432-3833
Mailing Address - Fax:847-432-1232
Practice Address - Street 1:1268 SHERIDAN RD
Practice Address - Street 2:
Practice Address - City:HIGHLAND PARK
Practice Address - State:IL
Practice Address - Zip Code:60035-4120
Practice Address - Country:US
Practice Address - Phone:847-432-3833
Practice Address - Fax:847-432-1232
Is Sole Proprietor?:No
Enumeration Date:2007-11-15
Last Update Date:2007-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist