Healthcare Provider Details

I. General information

NPI: 1891137006
Provider Name (Legal Business Name): WILLIAM CECRLE MOT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/29/2013
Last Update Date: 03/14/2022
Certification Date: 03/14/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2398 W ANTLER AVE
REDMOND OR
97756-9330
US

IV. Provider business mailing address

685 36TH AVE NE
SALEM OR
97301-4741
US

V. Phone/Fax

Practice location:
  • Phone: 541-408-1373
  • Fax: 866-914-5194
Mailing address:
  • Phone: 503-540-8701
  • Fax: 503-371-8772

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number2591
License Number StateOR
# 2
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number312826
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: