=====================================================
General NPI Number Information
=====================================================
NPI Number | 1285397828
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MISS MARISA OLIVER
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/20/2021
-----------------------------------------------------
Last Update Date | 10/20/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1510 REEVESVILLE RD
-----------------------------------------------------
City | GRANTSBURG
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 62943-2016
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 618-771-2144
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1510 REEVESVILLE RD
-----------------------------------------------------
City | GRANTSBURG
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 62943-2016
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 618-771-2144
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225200000X
-----------------------------------------------------
Taxonomy Name | Physical Therapy Assistant
-----------------------------------------------------
License Number | 160.008838
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------