Basic Information
| Provider Information | |||||||||
| NPI: | 1891162145 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | LESERMAN | ||||||||
| FirstName: | ELLEN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 624 W BARRY AVE | ||||||||
| Address2: | APT. 2W | ||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 606574540 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3105678659 | ||||||||
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| Practice Location | |||||||||
| Address1: | 3703 W LAKE AVE | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | GLENVIEW | ||||||||
| State: | IL | ||||||||
| PostalCode: | 600265823 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8479981188 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/21/2015 | ||||||||
| LastUpdateDate: | 08/21/2015 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225X00000X | 056011123 | IL | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist |
No ID Information.