Provider Demographics
NPI:1134362981
Name:SUSMENA, GERARD BALGOS (OTR/L)
Entity type:Individual
Prefix:MR
First Name:GERARD
Middle Name:BALGOS
Last Name:SUSMENA
Suffix:
Gender:M
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1326 W COLUMBIA AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60626-4326
Mailing Address - Country:US
Mailing Address - Phone:773-490-6232
Mailing Address - Fax:
Practice Address - Street 1:7434 NORTH HERMITAGE AVENUE #3B
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60626-1639
Practice Address - Country:US
Practice Address - Phone:847-951-0097
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-04-09
Last Update Date:2016-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL056.007.661225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist