Basic Information
| Provider Information | |||||||||
| NPI: | 1174531370 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MEISMER | ||||||||
| FirstName: | MARY | ||||||||
| MiddleName: | A | ||||||||
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| Credential: | OTR/L, CHT (NBCOT) | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1111 TRINITY LN | ||||||||
| Address2: | SUITE 111 | ||||||||
| City: | BLOOMINGTON | ||||||||
| State: | IL | ||||||||
| PostalCode: | 617048111 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3096636461 | ||||||||
| FaxNumber: | 3096618107 | ||||||||
| Practice Location | |||||||||
| Address1: | 1111 TRINITY LN | ||||||||
| Address2: | SUITE 111 | ||||||||
| City: | BLOOMINGTON | ||||||||
| State: | IL | ||||||||
| PostalCode: | 617048111 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3096636461 | ||||||||
| FaxNumber: | 3096618107 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/03/2006 | ||||||||
| LastUpdateDate: | 01/04/2017 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225X00000X | 056000370 | IL | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist | 225XH1200X | 056000370 | IL | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist | Hand |
ID Information
| ID | Type | State | Issuer | Description | 056.000370 | 01 | IL | STATE LICENSE | OTHER |