Provider Demographics
NPI:1740445899
Name:MUTZ, MEGAN LYNN (COTA/L)
Entity type:Individual
Prefix:MRS
First Name:MEGAN
Middle Name:LYNN
Last Name:MUTZ
Suffix:
Gender:F
Credentials:COTA/L
Other - Prefix:MS
Other - First Name:MEGAN
Other - Middle Name:LYNN
Other - Last Name:DIEDRICH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:COTA/L
Mailing Address - Street 1:850 BROOK FOREST AVE
Mailing Address - Street 2:UNIT M
Mailing Address - City:SHOREWOOD
Mailing Address - State:IL
Mailing Address - Zip Code:60404
Mailing Address - Country:US
Mailing Address - Phone:815-730-1800
Mailing Address - Fax:815-730-1835
Practice Address - Street 1:850 BROOK FOREST AVE
Practice Address - Street 2:UNIT L
Practice Address - City:SHOREWOOD
Practice Address - State:IL
Practice Address - Zip Code:60404
Practice Address - Country:US
Practice Address - Phone:312-943-3600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-07-28
Last Update Date:2014-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL057002970224Z00000X
225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
No224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant