Healthcare Provider Details

I. General information

NPI: 1316091036
Provider Name (Legal Business Name): DIANNE M TENNANT RUCKER OTRL
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/22/2007
Last Update Date: 07/09/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

905 N RIVERVIEW LN
MAHOMET IL
61853-9768
US

IV. Provider business mailing address

905 N RIVERVIEW LN
MAHOMET IL
61853-9768
US

V. Phone/Fax

Practice location:
  • Phone: 217-621-5429
  • Fax: 866-267-2080
Mailing address:
  • Phone: 217-621-5429
  • Fax: 866-267-2080

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License NumberDM58211298P
License Number StateIL

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier371389210
Identifier TypeMEDICAID
Identifier StateIL
Identifier Issuer
# 2
IdentifierDM58211298P
Identifier TypeOTHER
Identifier StateIL
Identifier IssuerIL OT LICNESE NUMBER
# 3
Identifier0001032002
Identifier TypeOTHER
Identifier StateIL
Identifier IssuerBLUE CROSS BLUE SHEILD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: