Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 225X00000X | Occupational Therapist | 3880 | MS |
N | 225XG0600X | Occupational Therapist - Gerontology | 056008720 | IL |
Y | 225XG0600X | Occupational Therapist - Gerontology | 3880 | MS |
N | 225XP0019X | Occupational Therapist - Physical Rehabilitation | 056008720 | IL |
NPI | 1376920058 |
---|---|
Provider Name | Michelle Ann Ytac Hedge |
First Address | Fort Smith, AR 72919-0001 |
Second Address | Orland Park, IL 60467-5602 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 01/05/2015 |
Last Update Date | 13/08/2021 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
1346420015 | (05) | AR |