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NPI Code Detail

MEDICARE: PAIGE SUE KROGH OTR/L

MEDICARE: PAIGE SUE KROGH 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
12255A2300XAthletic Trainer
2390200000XStudent in an Organized Health Care Education/Training Program
3225X00000XOccupational Therapist

General Provider Information

NPI Number : 1750849782
Entity Type Code : Individual
Provider Name (Legal Business Name) : PAIGE SUE KROGH OTR/L
Provider Business Mailing Address
First Line : 2806 N KNOXVILLE AVE
Second Line :
City : PEORIA
State : IL
Zip : 61604-2870
Country : US
Telephone Number :
Fax Number :
Provider Business Practice Location Address
First Line : 2806 N KNOXVILLE AVE
Second Line :
City : PEORIA
State : IL
Zip : 61604-2870
Country : US
Telephone Number : 309-655-6961
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 03/08/2019
Last Update Date : 08/08/2022

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