Provider Demographics
NPI:1922290774
Name:BANJAVCIC, SUSAN JEAN (COTA L)
Entity Type:Individual
Prefix:MRS
First Name:SUSAN
Middle Name:JEAN
Last Name:BANJAVCIC
Suffix:
Gender:F
Credentials:COTA L
Other - Prefix:
Other - First Name:SUSAN
Other - Middle Name:
Other - Last Name:ARMSTRONG
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:650 ACADEMIC DRIVE
Mailing Address - Street 2:SCHOOL DISTRICT #158
Mailing Address - City:ALGONQUIN
Mailing Address - State:IL
Mailing Address - Zip Code:60102
Mailing Address - Country:US
Mailing Address - Phone:847-659-6158
Mailing Address - Fax:847-659-6122
Practice Address - Street 1:650 ACADEMIC DRIVE
Practice Address - Street 2:SCHOOL DISTRICT #158
Practice Address - City:ALGONQUIN
Practice Address - State:IL
Practice Address - Zip Code:60102
Practice Address - Country:US
Practice Address - Phone:847-659-6158
Practice Address - Fax:847-659-6122
Is Sole Proprietor?:No
Enumeration Date:2007-08-15
Last Update Date:2007-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant