Provider Demographics
NPI:1447917380
Name:CALVERT, CORISSA MARIE (OTR/L)
Entity type:Individual
Prefix:
First Name:CORISSA
Middle Name:MARIE
Last Name:CALVERT
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:CORY
Other - Middle Name:MARIE
Other - Last Name:CALVERT
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:OTR/L
Mailing Address - Street 1:310 N LOOMIS ST
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60607-1147
Mailing Address - Country:US
Mailing Address - Phone:312-243-8487
Mailing Address - Fax:
Practice Address - Street 1:310 N LOOMIS ST
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60607-1147
Practice Address - Country:US
Practice Address - Phone:312-243-8487
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-11-28
Last Update Date:2021-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL056.014523225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist