Healthcare Provider Details

I. General information

NPI: 1497898191
Provider Name (Legal Business Name): GLADY REYES OTRL
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/14/2007
Last Update Date: 01/06/2023
Certification Date: 01/06/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1410 STATE ST
OTTAWA IL
61350-4735
US

IV. Provider business mailing address

1410 STATE ST
OTTAWA IL
61350-4735
US

V. Phone/Fax

Practice location:
  • Phone: 630-408-3822
  • Fax: 815-313-5283
Mailing address:
  • Phone: 630-408-3822
  • Fax: 815-313-5283

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code222Q00000X
TaxonomyDevelopmental Therapist
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code225XP0200X
TaxonomyPediatric Occupational Therapist
License Number056.002994
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: