Individual
KOKO SOLENE BURRUSS
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
DT
Contact information
Practice address
1258 S CANAL ST, CHICAGO, IL 60607-5213
(312) 925-7962
Mailing address
4901 S DREXEL BLVD, CHICAGO, IL 60615-2746
Taxonomy
Speciality
Code
Description
License number
State
222Q00000X
Developmental Therapist
Primary
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
0000000000
—
IL
Enumeration date
06/26/2017
Last updated
06/26/2017
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