Provider Demographics
NPI:1831219492
Name:HERMIDA-VAN HORN, SUSAN KATHERINE (OTR)
Entity type:Individual
Prefix:MS
First Name:SUSAN
Middle Name:KATHERINE
Last Name:HERMIDA-VAN HORN
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 1:1020 N MOZART ST
Mailing Address - Street 2:#1
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60622-1575
Mailing Address - Country:US
Mailing Address - Phone:312-493-1493
Mailing Address - Fax:773-256-5060
Practice Address - Street 1:5548 S HYDE PARK BLVD
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60637-1909
Practice Address - Country:US
Practice Address - Phone:773-256-5050
Practice Address - Fax:773-256-5060
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist