MEDICARE: JAN WALDT OT

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225X00000X	Occupational Therapist

General Provider Information

NPI Number	:	1043579683
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JAN WALDT OT

Provider Business Mailing Address
First Line	:	790 REMINGTON BLVD
Second Line	:
City	:	BOLINGBROOK
State	:	IL
Zip	:	60440-4909
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	727 SE MAIN ST STE 200
Second Line	:
City	:	SIMPSONVILLE
State	:	SC
Zip	:	29681-3262
Country	:	US
Telephone Number	:	864-454-6670
Fax Number	:	864-454-6675

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/15/2012
Last Update Date	:	11/22/2023

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