Healthcare Provider Details

I. General information

NPI: 1649285099
Provider Name (Legal Business Name): GRETCHEN R. SPROUSE O.T.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/31/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 NE RANDOLPH AVE
PEORIA IL
61606-1919
US

IV. Provider business mailing address

530 NE GLEN OAK AVE
PEORIA IL
61637-0001
US

V. Phone/Fax

Practice location:
  • Phone: 309-624-8578
  • Fax: 309-624-8566
Mailing address:
  • Phone: 309-655-2000
  • Fax: 309-655-7869

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: