Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 224Z00000X | Occupational Therapy Assistant | 057001621 | IL |
NPI | 1023363132 |
---|---|
Provider Name | Ellen Marie Warner |
First Address | Collinsville, IL 62234-3882 |
Second Address | Caseyville, IL 62232-1306 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 16/07/2012 |
Last Update Date | 16/07/2012 |