Provider Demographics
NPI:1861725210
Name:HENNESSY, SUE A (OTR/L)
Entity type:Individual
Prefix:
First Name:SUE
Middle Name:A
Last Name:HENNESSY
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 1:3132 MARYLAND RD
Mailing Address - Street 2:
Mailing Address - City:ROCKFORD
Mailing Address - State:IL
Mailing Address - Zip Code:61108-5918
Mailing Address - Country:US
Mailing Address - Phone:815-399-5079
Mailing Address - Fax:
Practice Address - Street 1:1905 W HART RD
Practice Address - Street 2:
Practice Address - City:BELOIT
Practice Address - State:WI
Practice Address - Zip Code:53511-2230
Practice Address - Country:US
Practice Address - Phone:608-365-7500
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-09-16
Last Update Date:2009-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI4663026225X00000X
IL056005699225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist