Provider Demographics
NPI:1962740530
Name:TAVAWALA, FARIDA K
Entity type:Individual
Prefix:
First Name:FARIDA
Middle Name:K
Last Name:TAVAWALA
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 1:470 FAWELL BLVD
Mailing Address - Street 2:APT 511
Mailing Address - City:GLEN ELLYN
Mailing Address - State:IL
Mailing Address - Zip Code:60137-6796
Mailing Address - Country:US
Mailing Address - Phone:201-743-9677
Mailing Address - Fax:
Practice Address - Street 1:470 FAWELL BLVD
Practice Address - Street 2:APT 511
Practice Address - City:GLEN ELLYN
Practice Address - State:IL
Practice Address - Zip Code:60137-6796
Practice Address - Country:US
Practice Address - Phone:201-743-9677
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-01-16
Last Update Date:2013-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL056.009971225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist