Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 225X00000X | Occupational Therapist | 056.006364 | IL |
NPI | 1003214883 |
---|---|
Provider Name | Pamela Taylor |
First Address | Godfrey, IL 62035-1767 |
Second Address | Godfrey, IL 62035-1767 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 10/12/2014 |
Last Update Date | 10/12/2014 |