Provider Demographics
NPI:1316668031
Name:MARTINICH, SUSAN (COTA)
Entity type:Individual
Prefix:
First Name:SUSAN
Middle Name:
Last Name:MARTINICH
Suffix:
Gender:F
Credentials:COTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3015 BANGOR LN
Mailing Address - Street 2:
Mailing Address - City:AURORA
Mailing Address - State:IL
Mailing Address - Zip Code:60504-6846
Mailing Address - Country:US
Mailing Address - Phone:708-334-7601
Mailing Address - Fax:
Practice Address - Street 1:2112 W GALENA BLVD STE 8-316
Practice Address - Street 2:
Practice Address - City:AURORA
Practice Address - State:IL
Practice Address - Zip Code:60506-3255
Practice Address - Country:US
Practice Address - Phone:630-661-7253
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-09-09
Last Update Date:2022-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL057005849224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant