Healthcare Provider Details

I. General information

NPI: 1619425394
Provider Name (Legal Business Name): ELIZABETH ANN DEUTSCH OT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/12/2016
Last Update Date: 06/08/2021
Certification Date: 06/08/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

700 E WALNUT ST
BLOOMINGTON IL
61701-3244
US

IV. Provider business mailing address

2604 BLARNEY STONE LN
BLOOMINGTON IL
61704-8412
US

V. Phone/Fax

Practice location:
  • Phone: 309-827-8004
  • Fax:
Mailing address:
  • Phone: 513-328-9275
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number2016030096
License Number StateMO
# 2
Primary TaxonomyN
Taxonomy Code225XP0200X
TaxonomyPediatric Occupational Therapist
License Number2302
License Number StateNE
# 3
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number056.013411
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: