Basic Information
| Provider Information | |||||||||
| NPI: | 1912396227 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GAINES | ||||||||
| FirstName: | TAYLOR | ||||||||
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| Credential: | OTR/L | ||||||||
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| Mailing Information | |||||||||
| Address1: | 410 E MACK AVE | ||||||||
| Address2: | |||||||||
| City: | OLNEY | ||||||||
| State: | IL | ||||||||
| PostalCode: | 624502319 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 410 E MACK AVE | ||||||||
| Address2: | |||||||||
| City: | OLNEY | ||||||||
| State: | IL | ||||||||
| PostalCode: | 624502319 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6183957421 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 01/10/2015 | ||||||||
| LastUpdateDate: | 01/10/2015 | ||||||||
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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 | 056.010352 | IL | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist | 225X00000X | 31005582A | IN | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist |
No ID Information.