Provider Demographics
NPI:1720291115
Name:SURA, GAMINEE PATEL (OTR/L)
Entity Type:Individual
Prefix:MRS
First Name:GAMINEE
Middle Name:PATEL
Last Name:SURA
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:MISS
Other - First Name:GAMINEE
Other - Middle Name:BHARAT
Other - Last Name:PATEL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OTR/L
Mailing Address - Street 1:2740 W ARMITAGE AVE
Mailing Address - Street 2:UNIT 403S
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60647-4240
Mailing Address - Country:US
Mailing Address - Phone:773-412-9849
Mailing Address - Fax:
Practice Address - Street 1:2740 W ARMITAGE AVE
Practice Address - Street 2:UNIT 403S
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60647-4240
Practice Address - Country:US
Practice Address - Phone:773-412-9849
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-08
Last Update Date:2009-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL056.006520225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL056006520OtherOT LICENSE
ILGP93470606POtherEARLY INTERVENTION CREDEN