Provider Demographics
NPI:1528172830
Name:FORD, VERONICA ARLEAN (OT)
Entity type:Individual
Prefix:MRS
First Name:VERONICA
Middle Name:ARLEAN
Last Name:FORD
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 1:9730 S LA SALLE ST
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60628-1332
Mailing Address - Country:US
Mailing Address - Phone:773-995-8572
Mailing Address - Fax:773-995-8845
Practice Address - Street 1:4400 W 95TH ST
Practice Address - Street 2:SUITE 106
Practice Address - City:OAK LAWN
Practice Address - State:IL
Practice Address - Zip Code:60453-2654
Practice Address - Country:US
Practice Address - Phone:708-422-7758
Practice Address - Fax:708-422-8154
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL056-002959225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL364183889-60628-01Medicaid