=====================================================
General NPI Number Information
=====================================================
NPI Number | 1508462102
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | LAURIE WEBER
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/09/2020
-----------------------------------------------------
Last Update Date | 12/09/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 423 N DIXIE HWY
-----------------------------------------------------
City | HOOPESTON
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60942-1021
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 217-283-8347
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1527 E 600 NORTH RD
-----------------------------------------------------
City | CISSNA PARK
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60924-8787
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 224Z00000X
-----------------------------------------------------
Taxonomy Name | Occupational Therapy Assistant
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------