Healthcare Provider Details

I. General information

NPI: 1063544401
Provider Name (Legal Business Name): STARVED ROCK REGIONAL CENTER FOR THERAPY & CHILD DEVELOPMENT
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/12/2007
Last Update Date: 06/19/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1013 ADAMS STREET
OTTAWA IL
61354-4304
US

IV. Provider business mailing address

1013 ADAMS STREET
OTTAWA IL
61354-4304
US

V. Phone/Fax

Practice location:
  • Phone: 815-434-0857
  • Fax: 815-434-2260
Mailing address:
  • Phone: 815-434-0857
  • Fax: 815-434-2260

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2081P0010X
TaxonomyPediatric Rehabilitation Medicine Physician
License Number
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number
License Number StateIL
# 3
Primary TaxonomyN
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number
License Number StateIL
# 4
Primary TaxonomyN
Taxonomy Code251V00000X
TaxonomyVoluntary or Charitable Agency
License Number
License Number State
# 5
Primary TaxonomyY
Taxonomy Code251V00000X
TaxonomyVoluntary or Charitable Agency
License Number
License Number StateIL

VIII. Authorized Official

Name: MRS. PAULA SUE WILLIAMSON
Title or Position: PROGRAM DIRECTOR
Credential:
Phone: 815-434-0857