Provider Demographics
NPI:1669896411
Name:ROTH, CHELSEY
Entity type:Individual
Prefix:
First Name:CHELSEY
Middle Name:
Last Name:ROTH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15898 E DAVIS RD
Mailing Address - Street 2:
Mailing Address - City:OPDYKE
Mailing Address - State:IL
Mailing Address - Zip Code:62872-3100
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:15898 E DAVIS RD
Practice Address - Street 2:
Practice Address - City:OPDYKE
Practice Address - State:IL
Practice Address - Zip Code:62872-3100
Practice Address - Country:US
Practice Address - Phone:618-310-9196
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-02-14
Last Update Date:2014-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL057.003438224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant