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General NPI Number Information
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NPI Number | 1457149791
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Entity Type | Individual
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Provider Name | GRACE MODGLIN
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Gender | Female
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Dates
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Enumeration Date | 04/28/2025
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Last Update Date | 04/28/2025
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Provider Practice Location Address
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Address Line | 821 W HIGHWAY 50
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City | O FALLON
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State | IL
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Zip | 62269-1828
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Country | US
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Telephone | 618-726-0370
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Fax |
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Provider Business Mailing Address
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Address Line | 35 HOLLY DR
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City | BELLEVILLE
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State | IL
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Zip | 62221-4500
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Country | US
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Telephone | 812-746-1491
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 225X00000X
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Taxonomy Name | Occupational Therapist
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License Number | 056.016532
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License Number State | IL
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