=====================================================
General NPI Number Information
=====================================================
NPI Number | 1316476849
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | OT PLAYWORKS INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/08/2017
-----------------------------------------------------
Last Update Date | 07/21/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1023 US HIGHWAY 45
-----------------------------------------------------
City | FAIRFIELD
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 62837-2909
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 618-895-4260
-----------------------------------------------------
Fax | 618-551-8835
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1023 US HIGHWAY 45
-----------------------------------------------------
City | FAIRFIELD
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 62837-2909
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 618-895-4260
-----------------------------------------------------
Fax | 618-551-8835
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER/THERAPIST
-----------------------------------------------------
Name | DEANA LYNNE HOSTETTLER
-----------------------------------------------------
Credential | MSOTR/L
-----------------------------------------------------
Telephone | 618-895-4260
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 252Y00000X
-----------------------------------------------------
Taxonomy Name | Early Intervention Provider Agency
-----------------------------------------------------
License Number | 056008112
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------