=====================================================
General NPI Number Information
=====================================================
NPI Number | 1780216176
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MARIAN CELESTE FRALEY OTR/L
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/04/2020
-----------------------------------------------------
Last Update Date | 02/04/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 301 PLEASANT DALE RD
-----------------------------------------------------
City | KAMPSVILLE
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 62053-4511
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 217-248-1007
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 301 PLEASANT DALE RD
-----------------------------------------------------
City | KAMPSVILLE
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 62053-4511
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 217-248-1007
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225X00000X
-----------------------------------------------------
Taxonomy Name | Occupational Therapist
-----------------------------------------------------
License Number | 056.002725
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------