Healthcare Provider Details

I. General information

NPI: 1811437981
Provider Name (Legal Business Name): SUZANNE ALLEN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/08/2017
Last Update Date: 03/08/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3032 BROADWAY ST
QUINCY IL
62301-3708
US

IV. Provider business mailing address

3032 BROADWAY ST
QUINCY IL
62301-3708
US

V. Phone/Fax

Practice location:
  • Phone: 217-222-6800
  • Fax:
Mailing address:
  • Phone: 217-222-6800
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number2017006765
License Number StateMO
# 2
Primary TaxonomyN
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number00000
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: