Provider Demographics
NPI:1306009246
Name:THAKE, BARBARA (OT/L)
Entity Type:Individual
Prefix:
First Name:BARBARA
Middle Name:
Last Name:THAKE
Suffix:
Gender:F
Credentials:OT/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19 LAKE RIDGE CT
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IL
Mailing Address - Zip Code:61701-1475
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2040 TIMBERBROOK DR
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:IL
Practice Address - Zip Code:62702-6623
Practice Address - Country:US
Practice Address - Phone:217-726-1946
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-07-09
Last Update Date:2008-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL056000212225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist