Provider Demographics
NPI:1528421187
Name:TANZILLO, KYLE (MOT, OTR/L)
Entity type:Individual
Prefix:
First Name:KYLE
Middle Name:
Last Name:TANZILLO
Suffix:
Gender:M
Credentials:MOT, OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:211 E OHIO ST
Mailing Address - Street 2:APT. 1411
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60611-3262
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:401 W LAKE ST
Practice Address - Street 2:
Practice Address - City:NORTHLAKE
Practice Address - State:IL
Practice Address - Zip Code:60164-2435
Practice Address - Country:US
Practice Address - Phone:708-365-9251
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-03-31
Last Update Date:2016-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL056011401225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist