Provider Demographics
NPI:1861620734
Name:SMITH, REGINA TUCKER (MS, OTR/L)
Entity type:Individual
Prefix:MS
First Name:REGINA
Middle Name:TUCKER
Last Name:SMITH
Suffix:
Gender:F
Credentials:MS, OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9410 S BELL AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60643-6743
Mailing Address - Country:US
Mailing Address - Phone:773-239-6912
Mailing Address - Fax:
Practice Address - Street 1:9410 S BELL AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60643-6743
Practice Address - Country:US
Practice Address - Phone:773-239-6912
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-06-30
Last Update Date:2009-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL056001484225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist