Provider Demographics
NPI:1841530847
Name:WURST, DAWN ENNIS (OTR/L)
Entity type:Individual
Prefix:
First Name:DAWN
Middle Name:ENNIS
Last Name:WURST
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1358 W SUNNYSIDE AVE # 1
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60640-5583
Mailing Address - Country:US
Mailing Address - Phone:248-840-1105
Mailing Address - Fax:
Practice Address - Street 1:1308 WAUKEGAN RD
Practice Address - Street 2:
Practice Address - City:GLENVIEW
Practice Address - State:IL
Practice Address - Zip Code:60025-3070
Practice Address - Country:US
Practice Address - Phone:877-486-4140
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-02-27
Last Update Date:2014-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL056010041225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist