Provider Demographics
NPI:1790040665
Name:FORD, KARLETTE RAESHAUN (COTA)
Entity Type:Individual
Prefix:MISS
First Name:KARLETTE
Middle Name:RAESHAUN
Last Name:FORD
Suffix:
Gender:F
Credentials:COTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:510 HICKOK AVE
Mailing Address - Street 2:
Mailing Address - City:UNIVERSITY PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60484-3038
Mailing Address - Country:US
Mailing Address - Phone:708-271-7880
Mailing Address - Fax:708-235-0741
Practice Address - Street 1:6006 159TH ST
Practice Address - Street 2:
Practice Address - City:OAK FOREST
Practice Address - State:IL
Practice Address - Zip Code:60452-2904
Practice Address - Country:US
Practice Address - Phone:708-535-0933
Practice Address - Fax:708-614-9435
Is Sole Proprietor?:No
Enumeration Date:2012-07-06
Last Update Date:2012-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL057.002017224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant