Provider Demographics
NPI:1215126305
Name:CULLOTTA, LORI ANN (OT)
Entity type:Individual
Prefix:
First Name:LORI
Middle Name:ANN
Last Name:CULLOTTA
Suffix:
Gender:F
Credentials:OT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11411 W 183RD ST
Mailing Address - Street 2:SUITE B
Mailing Address - City:ORLAND PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60467-9450
Mailing Address - Country:US
Mailing Address - Phone:708-478-1820
Mailing Address - Fax:708-478-3316
Practice Address - Street 1:11411 W 183RD ST
Practice Address - Street 2:SUITE B
Practice Address - City:ORLAND PARK
Practice Address - State:IL
Practice Address - Zip Code:60467-9450
Practice Address - Country:US
Practice Address - Phone:708-478-1820
Practice Address - Fax:708-478-3316
Is Sole Proprietor?:No
Enumeration Date:2007-10-15
Last Update Date:2012-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL056008170225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL09932114OtherBCBS ILLINOIS
ILLB04761207PMedicaid