Provider Demographics
NPI:1023635364
Name:DIRKS, CRYSTAL MARY (COTA/L)
Entity type:Individual
Prefix:MRS
First Name:CRYSTAL
Middle Name:MARY
Last Name:DIRKS
Suffix:
Gender:F
Credentials:COTA/L
Other - Prefix:MISS
Other - First Name:CRYSTAL
Other - Middle Name:MARY
Other - Last Name:PEDZIEWIATR
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:COTA/L
Mailing Address - Street 1:1S221 EUCLID AVE
Mailing Address - Street 2:
Mailing Address - City:VILLA PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60181-3902
Mailing Address - Country:US
Mailing Address - Phone:630-995-0408
Mailing Address - Fax:
Practice Address - Street 1:211 75TH ST
Practice Address - Street 2:
Practice Address - City:BURR RIDGE
Practice Address - State:IL
Practice Address - Zip Code:60527
Practice Address - Country:US
Practice Address - Phone:630-230-1170
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-07-02
Last Update Date:2020-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL057004588224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant