Basic Information
| Provider Information | |||||||||
| NPI: | 1750657581 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | EATOCK | ||||||||
| FirstName: | KATIE | ||||||||
| MiddleName: | JOANNE | ||||||||
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| Credential: | O.T. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2213 GRAND AVE | ||||||||
| Address2: | |||||||||
| City: | DES MOINES | ||||||||
| State: | IA | ||||||||
| PostalCode: | 503125305 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5152373974 | ||||||||
| FaxNumber: | 5158832692 | ||||||||
| Practice Location | |||||||||
| Address1: | 758 216TH DR | ||||||||
| Address2: | |||||||||
| City: | OGDEN | ||||||||
| State: | IA | ||||||||
| PostalCode: | 502127520 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5152754003 | ||||||||
| FaxNumber: | 5152754122 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/27/2012 | ||||||||
| LastUpdateDate: | 03/27/2012 | ||||||||
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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 | 001982 | IA | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist |
ID Information
| ID | Type | State | Issuer | Description | IN PROCESS | 05 | IA | MEDICAID |