MEDICARE: CRICKET PORTER

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	:	1962345397
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CRICKET PORTER

Provider Business Mailing Address
First Line	:	2000 JACOBSSEN DR
Second Line	:
City	:	NORMAL
State	:	IL
Zip	:	61761-6277
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1302 FRANKLIN AVE UNIT L500
Second Line	:
City	:	NORMAL
State	:	IL
Zip	:	61761-3551
Country	:	US
Telephone Number	:	309-452-0069
Fax Number	:

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

Provider Enumeration Date	:	04/10/2026
Last Update Date	:	04/10/2026

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Directions to “ CRICKET PORTER ” Practice Location

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