Healthcare Provider Details

I. General information

NPI: 1346355658
Provider Name (Legal Business Name): SEAN B SMITH O.T
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/20/2006
Last Update Date: 02/14/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

525 S SWEETBRIAR DR
CHILLICOTHEE IL
61523-2264
US

IV. Provider business mailing address

525 S SWEETBRIAR DR
CHILLICOTHEE IL
61523-2264
US

V. Phone/Fax

Practice location:
  • Phone: 309-274-6314
  • Fax: 309-274-4100
Mailing address:
  • Phone: 309-274-6314
  • Fax: 309-274-4100

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number056-007640
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: