Provider Demographics
NPI:1750601605
Name:DAVID, KATRINA MORTA (OTRL)
Entity type:Individual
Prefix:MISS
First Name:KATRINA
Middle Name:MORTA
Last Name:DAVID
Suffix:
Gender:F
Credentials:OTRL
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2320 PEBBLESTONE WAY
Mailing Address - Street 2:
Mailing Address - City:BOLINGBROOK
Mailing Address - State:IL
Mailing Address - Zip Code:60490-5059
Mailing Address - Country:US
Mailing Address - Phone:815-782-4619
Mailing Address - Fax:
Practice Address - Street 1:2320 PEBBLESTONE WAY
Practice Address - Street 2:
Practice Address - City:BOLINGBROOK
Practice Address - State:IL
Practice Address - Zip Code:60490-5059
Practice Address - Country:US
Practice Address - Phone:815-782-4619
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-06-02
Last Update Date:2012-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL056.007949225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist