Provider Demographics
NPI:1407958010
Name:BIRKNER, MINDY A (OTD,OTR/L)
Entity Type:Individual
Prefix:DR
First Name:MINDY
Middle Name:A
Last Name:BIRKNER
Suffix:
Gender:F
Credentials:OTD,OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:21921 DOVE LN
Mailing Address - Street 2:
Mailing Address - City:CARLYLE
Mailing Address - State:IL
Mailing Address - Zip Code:62231-4717
Mailing Address - Country:US
Mailing Address - Phone:618-971-6979
Mailing Address - Fax:618-749-2041
Practice Address - Street 1:21921 DOVE LN
Practice Address - Street 2:
Practice Address - City:CARLYLE
Practice Address - State:IL
Practice Address - Zip Code:62231-4717
Practice Address - Country:US
Practice Address - Phone:618-971-6979
Practice Address - Fax:618-749-2041
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-03
Last Update Date:2008-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL056007264225XP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL06032139OtherBLUE SHIELD PROVIDER NUMB