Healthcare Provider Details

I. General information

NPI: 1346284007
Provider Name (Legal Business Name): JAMES D DELOACH JR. OT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

Provider Other Name: DOUG DELOACH

II. Dates (important events)

Enumeration Date: 06/15/2006
Last Update Date: 03/02/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

76359 AL HIGHWAY 77 SUITE B
LINCOLN AL
35096-5039
US

IV. Provider business mailing address

790 REMINGTON BLVD
BOLINGBROOK IL
60440-4909
US

V. Phone/Fax

Practice location:
  • Phone: 630-296-2222
  • Fax:
Mailing address:
  • Phone: 630-296-2222
  • Fax: 630-759-9510

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number0815
License Number StateAL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: