Provider Demographics
NPI:1043569270
Name:BAUCOM, KOLINA ARLENE (OT)
Entity Type:Individual
Prefix:
First Name:KOLINA
Middle Name:ARLENE
Last Name:BAUCOM
Suffix:
Gender:F
Credentials:OT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3032 BROADWAY ST
Mailing Address - Street 2:
Mailing Address - City:QUINCY
Mailing Address - State:IL
Mailing Address - Zip Code:62301-3708
Mailing Address - Country:US
Mailing Address - Phone:217-222-6800
Mailing Address - Fax:217-222-0037
Practice Address - Street 1:620 WABASH AVE
Practice Address - Street 2:
Practice Address - City:CARTHAGE
Practice Address - State:IL
Practice Address - Zip Code:62321-1444
Practice Address - Country:US
Practice Address - Phone:217-357-9000
Practice Address - Fax:217-357-9013
Is Sole Proprietor?:No
Enumeration Date:2012-09-04
Last Update Date:2016-10-26
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
IL056009839225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist