Provider Demographics
NPI:1063974343
Name:PAUL, KAILAN NICOLE KATHRYN (OTR/L)
Entity type:Individual
Prefix:MS
First Name:KAILAN
Middle Name:NICOLE KATHRYN
Last Name:PAUL
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 1:21000 FRANKFORT SQUARE ROAD STE D (WESTSIDE CHILDREN'S
Mailing Address - Street 2:
Mailing Address - City:FRANKFORT
Mailing Address - State:IL
Mailing Address - Zip Code:60423
Mailing Address - Country:US
Mailing Address - Phone:815-469-1500
Mailing Address - Fax:815-220-5619
Practice Address - Street 1:21000 S. FRANKFORT SQUARE ROAD, SUITE D
Practice Address - Street 2:
Practice Address - City:FRANKFORT
Practice Address - State:IL
Practice Address - Zip Code:60423
Practice Address - Country:US
Practice Address - Phone:815-469-1500
Practice Address - Fax:815-220-5619
Is Sole Proprietor?:No
Enumeration Date:2019-04-04
Last Update Date:2019-11-18
Deactivation Date:2019-11-07
Deactivation Code:
Reactivation Date:2019-11-18
Provider Licenses
StateLicense IDTaxonomies
IL056.012526225XP0200X, 225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
No225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatrics