Provider Demographics
NPI:1053587915
Name:WHITLOCK ROBERTSON, GLORIA JEAN
Entity type:Individual
Prefix:MS
First Name:GLORIA
Middle Name:JEAN
Last Name:WHITLOCK ROBERTSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:GLORIA
Other - Middle Name:
Other - Last Name:ROBERTSON
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:CERTIFIED
Mailing Address - Street 1:3008 139TH PL
Mailing Address - Street 2:
Mailing Address - City:BLUE ISLAND
Mailing Address - State:IL
Mailing Address - Zip Code:60406-3345
Mailing Address - Country:US
Mailing Address - Phone:708-489-0469
Mailing Address - Fax:
Practice Address - Street 1:21020 KOSTNER AVE
Practice Address - Street 2:
Practice Address - City:MATTESON
Practice Address - State:IL
Practice Address - Zip Code:60443-2068
Practice Address - Country:US
Practice Address - Phone:708-747-1300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-05-01
Last Update Date:2008-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL057002512225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist