Provider Demographics
NPI:1831834464
Name:WILLARD, KRISTIN (MOT)
Entity type:Individual
Prefix:
First Name:KRISTIN
Middle Name:
Last Name:WILLARD
Suffix:
Gender:F
Credentials:MOT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:150 FOREST AVE UNIT 2014
Mailing Address - Street 2:
Mailing Address - City:OAK PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60301-1463
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:820 NORTH BLVD
Practice Address - Street 2:
Practice Address - City:OAK PARK
Practice Address - State:IL
Practice Address - Zip Code:60301-1351
Practice Address - Country:US
Practice Address - Phone:708-524-2445
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-04-28
Last Update Date:2022-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL056014689225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist