Basic Information
| Provider Information | |||||||||
| NPI: | 1700351814 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | EDWARDS | ||||||||
| FirstName: | KATIE | ||||||||
| MiddleName: | C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2217 N 5TH ST | ||||||||
| Address2: | |||||||||
| City: | CLINTON | ||||||||
| State: | IA | ||||||||
| PostalCode: | 527322149 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5633211901 | ||||||||
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| Practice Location | |||||||||
| Address1: | 308 S 2ND ST | ||||||||
| Address2: | |||||||||
| City: | WALNUT | ||||||||
| State: | IL | ||||||||
| PostalCode: | 613769364 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8153792131 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 10/05/2018 | ||||||||
| LastUpdateDate: | 02/26/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 02/26/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 224Z00000X | 089435 | IA | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapy Assistant | 224Z00000X | 057004856 | IL | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapy Assistant |
ID Information
| ID | Type | State | Issuer | Description | 057004856 | 01 | IL | ILLINOIS DEPARTMENT OF FINANCIAL AND PROFESSIONAL REGULATION | OTHER |