=====================================================
General NPI Number Information
=====================================================
NPI Number | 1760888465
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | BETHANY ROHL
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/07/2014
-----------------------------------------------------
Last Update Date | 11/07/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1425 W LINCOLN HWY
-----------------------------------------------------
City | DEKALB
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60115-2825
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 815-753-1401
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1425 W LINCOLN HWY
-----------------------------------------------------
City | DEKALB
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60115-2828
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2255A2300X
-----------------------------------------------------
Taxonomy Name | Athletic Trainer
-----------------------------------------------------
License Number | 2601001345
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 2255A2300X
-----------------------------------------------------
Taxonomy Name | Athletic Trainer
-----------------------------------------------------
License Number | 096004253
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------