Provider Demographics
NPI:1992821227
Name:WYANT, JULIE K (OTR)
Entity type:Individual
Prefix:
First Name:JULIE
Middle Name:K
Last Name:WYANT
Suffix:
Gender:F
Credentials:OTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:734 N HORIZON CT
Mailing Address - Street 2:
Mailing Address - City:LINDENHURST
Mailing Address - State:IL
Mailing Address - Zip Code:60046-7868
Mailing Address - Country:US
Mailing Address - Phone:847-975-5508
Mailing Address - Fax:847-265-4523
Practice Address - Street 1:734 N HORIZON CT
Practice Address - Street 2:
Practice Address - City:LINDENHURST
Practice Address - State:IL
Practice Address - Zip Code:60046-7868
Practice Address - Country:US
Practice Address - Phone:847-975-5508
Practice Address - Fax:847-265-4523
Is Sole Proprietor?:No
Enumeration Date:2007-03-21
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL225XP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL4932405Medicare UPIN