Basic Information
| Provider Information | |||||||||
| NPI: | 1053554410 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | CERVANTES | ||||||||
| FirstName: | DEXTER | ||||||||
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| Credential: | O.T. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1920 OLD SPRINGVILLE RD | ||||||||
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| City: | BIRMINGHAM | ||||||||
| State: | AL | ||||||||
| PostalCode: | 352155858 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2055209600 | ||||||||
| FaxNumber: | 2055200455 | ||||||||
| Practice Location | |||||||||
| Address1: | 221 NE GLEN OAK AVE | ||||||||
| Address2: | |||||||||
| City: | PEORIA | ||||||||
| State: | IL | ||||||||
| PostalCode: | 616360002 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3096725522 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 04/15/2009 | ||||||||
| LastUpdateDate: | 05/31/2011 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225X00000X | 056008282 | IL | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist |
No ID Information.