Basic Information
| Provider Information | |||||||||
| NPI: | 1447803507 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SMITH | ||||||||
| FirstName: | ISABELLA | ||||||||
| MiddleName: | RUBY | ||||||||
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| Credential: | COTA/L | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | MILHAUSER | ||||||||
| OtherFirstName: | ISABELLA | ||||||||
| OtherMiddleName: | RUBY | ||||||||
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| OtherCredential: | COTA/L | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 503 GIANT CITY RD | ||||||||
| Address2: | |||||||||
| City: | MONTICELLO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 618568189 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2174540612 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 4112 FIELDSTONE RD | ||||||||
| Address2: | SUITE B | ||||||||
| City: | CHAMPAIGN | ||||||||
| State: | IL | ||||||||
| PostalCode: | 61822 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8883083728 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/18/2019 | ||||||||
| LastUpdateDate: | 07/18/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 224Z00000X | 057004851 | IL | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapy Assistant |
No ID Information.