MEDICARE: MICHELLE R PRUNEDA MOT, OTR/L

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225X00000X	Occupational Therapist	056.012912	IL

General Provider Information

NPI Number	:	1073070827
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MICHELLE R PRUNEDA MOT, OTR/L

Provider Business Mailing Address
First Line	:	448 MARIAN AVE
Second Line	:
City	:	BRADLEY
State	:	IL
Zip	:	60915-1940
Country	:	US
Telephone Number	:	815-295-3577
Fax Number	:

Provider Business Practice Location Address
First Line	:	504 5TH ST
Second Line	:
City	:	CRETE
State	:	IL
Zip	:	60417-2110
Country	:	US
Telephone Number	:	708-829-0059
Fax Number	:	708-367-9905

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/28/2019
Last Update Date	:	02/28/2019

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