Provider Demographics
NPI:1871149450
Name:THOM, CHRISTINA (OTRL)
Entity type:Individual
Prefix:
First Name:CHRISTINA
Middle Name:
Last Name:THOM
Suffix:
Gender:F
Credentials:OTRL
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3450 N LAKE SHORE DR APT 3506
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60657-2864
Mailing Address - Country:US
Mailing Address - Phone:734-634-0564
Mailing Address - Fax:
Practice Address - Street 1:3450 N LAKE SHORE DR APT 3506
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60657-2864
Practice Address - Country:US
Practice Address - Phone:734-634-0564
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-08-10
Last Update Date:2019-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5201008754225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist