Healthcare Provider Details

I. General information

NPI: 1093564924
Provider Name (Legal Business Name): KATE EDGAR
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/14/2024
Last Update Date: 05/14/2024
Certification Date: 05/14/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2810 FRANK SCOTT PKWY W STE 824
BELLEVILLE IL
62223-5007
US

IV. Provider business mailing address

520 BURROUGHS AVE
COLLINSVILLE IL
62234-3513
US

V. Phone/Fax

Practice location:
  • Phone: 618-234-9705
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code224Z00000X
TaxonomyOccupational Therapy Assistant
License Number057003537
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: