Provider Demographics
NPI:1366860017
Name:PITTELLI, ROSE
Entity type:Individual
Prefix:
First Name:ROSE
Middle Name:
Last Name:PITTELLI
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11334 S CHAMPLAIN AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60628-5122
Mailing Address - Country:US
Mailing Address - Phone:773-680-8745
Mailing Address - Fax:
Practice Address - Street 1:10300 SOUTHWEST HWY
Practice Address - Street 2:
Practice Address - City:CHICAGO RIDGE
Practice Address - State:IL
Practice Address - Zip Code:60415-1426
Practice Address - Country:US
Practice Address - Phone:708-425-1100
Practice Address - Fax:708-425-0209
Is Sole Proprietor?:Yes
Enumeration Date:2014-03-31
Last Update Date:2014-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL057.000622224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant