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NPI Code Detail

MEDICARE: SHELLY LILLY SLEDGE OTA/L

MEDICARE: SHELLY LILLY SLEDGE OTA/L
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
1224Z00000XOccupational Therapy Assistant057003285IL

General Provider Information

NPI Number : 1548896582
Entity Type Code : Individual
Provider Name (Legal Business Name) : SHELLY LILLY SLEDGE OTA/L
Provider Business Mailing Address
First Line : 12202 E MIDDLE RD
Second Line :
City : TEXICO
State : IL
Zip : 62889-2804
Country : US
Telephone Number : 618-237-6070
Fax Number :
Provider Business Practice Location Address
First Line : 1910 E MCCORD ST
Second Line :
City : CENTRALIA
State : IL
Zip : 62801-6586
Country : US
Telephone Number : 618-533-1200
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 03/22/2020
Last Update Date : 03/22/2020

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