Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 225X00000X | Occupational Therapist | 056.007160 | IL |
NPI | 1003163379 |
---|---|
Provider Name | Mr. Jason N Richards |
First Address | Normal, IL 61761-6286 |
Second Address | Normal, IL 61761-6286 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 06/08/2012 |
Last Update Date | 06/08/2012 |