Healthcare Provider Details

I. General information

NPI: 1376920058
Provider Name (Legal Business Name): MICHELLE ANN YTAC HEDGE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/01/2015
Last Update Date: 08/13/2021
Certification Date: 08/13/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

16170 KINGSPORT RD
ORLAND PARK IL
60467-5602
US

IV. Provider business mailing address

1000 FIANNA WAY
FORT SMITH AR
72919-0001
US

V. Phone/Fax

Practice location:
  • Phone: 708-326-1550
  • Fax: 708-326-1557
Mailing address:
  • Phone: 479-201-4835
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number3880
License Number StateMS
# 2
Primary TaxonomyN
Taxonomy Code225XG0600X
TaxonomyGerontology Occupational Therapist
License Number056008720
License Number StateIL
# 3
Primary TaxonomyN
Taxonomy Code225XP0019X
TaxonomyPhysical Rehabilitation Occupational Therapist
License Number056008720
License Number StateIL
# 4
Primary TaxonomyY
Taxonomy Code225XG0600X
TaxonomyGerontology Occupational Therapist
License Number3880
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: