Healthcare Provider Details

I. General information

NPI: 1043569270
Provider Name (Legal Business Name): KOLINA ARLENE BAUCOM O.T.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/04/2012
Last Update Date: 10/26/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

620 WABASH AVE
CARTHAGE IL
62321-1444
US

IV. Provider business mailing address

3032 BROADWAY ST
QUINCY IL
62301-3708
US

V. Phone/Fax

Practice location:
  • Phone: 217-357-9000
  • Fax: 217-357-9013
Mailing address:
  • Phone: 217-222-6800
  • Fax: 217-222-0037

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number056009839
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: