Basic Information
| Provider Information | |||||||||
| NPI: | 1396483756 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BURTON | ||||||||
| FirstName: | MARCIE | ||||||||
| MiddleName: | R | ||||||||
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| Credential: | COTA/L | ||||||||
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| OtherLastName: | GAHM | ||||||||
| OtherFirstName: | MARCIE | ||||||||
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| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 1708 N AURORA ST | ||||||||
| Address2: | |||||||||
| City: | PONTIAC | ||||||||
| State: | IL | ||||||||
| PostalCode: | 617641201 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 300 E MAZON AVE | ||||||||
| Address2: | |||||||||
| City: | DWIGHT | ||||||||
| State: | IL | ||||||||
| PostalCode: | 604201104 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8155841240 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/25/2022 | ||||||||
| LastUpdateDate: | 05/25/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 05/25/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 224ZE0001X | 057002456 | IL | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapy Assistant | Environmental Modification |
No ID Information.