Provider Demographics
NPI:1306161393
Name:PANCHOLI, VIKRAM (OTR/L)
Entity type:Individual
Prefix:MR
First Name:VIKRAM
Middle Name:
Last Name:PANCHOLI
Suffix:
Gender:M
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 1:660 W WAYMAN ST
Mailing Address - Street 2:#304
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60661-1296
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:660 W WAYMAN ST
Practice Address - Street 2:#304
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60661-1296
Practice Address - Country:US
Practice Address - Phone:313-283-8194
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-04-01
Last Update Date:2010-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL056007227225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist