Basic Information
Provider Information | |||||||||
NPI: | 1841865177 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | GRANDOLFO | ||||||||
FirstName: | TARA | ||||||||
MiddleName: | RYAN | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | OTR/L | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 4723 W PEBBLE BEACH DR | ||||||||
Address2: |   | ||||||||
City: | WADSWORTH | ||||||||
State: | IL | ||||||||
PostalCode: | 600839276 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2244365624 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 550 RIDGEVIEW DR | ||||||||
Address2: |   | ||||||||
City: | MCHENRY | ||||||||
State: | IL | ||||||||
PostalCode: | 60050 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8159002500 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 05/20/2021 | ||||||||
LastUpdateDate: | 05/20/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 04/29/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225X00000X | 452293 | IL | Y |   | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist |   |
ID Information
ID | Type | State | Issuer | Description | 452293 | 01 | IL | NBCOT | OTHER |