Provider Demographics
NPI:1699551523
Name:WANG, ELLEN QI (OTR/L)
Entity type:Individual
Prefix:
First Name:ELLEN
Middle Name:QI
Last Name:WANG
Suffix:
Gender:F
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 1:100 CHICAGO AVE
Mailing Address - Street 2:APT 405
Mailing Address - City:EVANSTON
Mailing Address - State:IL
Mailing Address - Zip Code:60202
Mailing Address - Country:US
Mailing Address - Phone:240-566-2282
Mailing Address - Fax:
Practice Address - Street 1:180 W HALF DAY RD
Practice Address - Street 2:
Practice Address - City:BUFFALO GROVE
Practice Address - State:IL
Practice Address - Zip Code:60089-6552
Practice Address - Country:US
Practice Address - Phone:847-478-8484
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-09-06
Last Update Date:2023-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL056015447225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist