Healthcare Provider Details

I. General information

NPI: 1699020552
Provider Name (Legal Business Name): SOUTHERN REHAB SPECIALISTS, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/17/2012
Last Update Date: 07/17/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3216 MUSTANG CT
HERRIN IL
62948-3783
US

IV. Provider business mailing address

3216 MUSTANG CT
HERRIN IL
62948-3783
US

V. Phone/Fax

Practice location:
  • Phone: 618-559-5610
  • Fax:
Mailing address:
  • Phone: 618-559-5610
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number056.007020
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number146.009800
License Number StateIL

VIII. Authorized Official

Name: SARAH RENEE SURPRENANT
Title or Position: OWNER, OCCUPATIONAL THERAPIST
Credential: OTR/L
Phone: 618-559-5610