Provider Demographics
NPI:1265712665
Name:MCDONOUGH, KERRI NICHOLE (OTR/L)
Entity type:Individual
Prefix:MRS
First Name:KERRI
Middle Name:NICHOLE
Last Name:MCDONOUGH
Suffix:
Gender:F
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 1:804 HUNTLEY WOODS DR
Mailing Address - Street 2:
Mailing Address - City:CRETE
Mailing Address - State:IL
Mailing Address - Zip Code:60417-1387
Mailing Address - Country:US
Mailing Address - Phone:708-672-4050
Mailing Address - Fax:
Practice Address - Street 1:804 HUNTLEY WOODS DR
Practice Address - Street 2:
Practice Address - City:CRETE
Practice Address - State:IL
Practice Address - Zip Code:60417-1387
Practice Address - Country:US
Practice Address - Phone:708-672-4050
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-08-17
Last Update Date:2011-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL056006555225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist