Provider Demographics
NPI:1447803507
Name:SMITH, ISABELLA RUBY (COTA/L)
Entity Type:Individual
Prefix:
First Name:ISABELLA
Middle Name:RUBY
Last Name:SMITH
Suffix:
Gender:F
Credentials:COTA/L
Other - Prefix:
Other - First Name:ISABELLA
Other - Middle Name:RUBY
Other - Last Name:MILHAUSER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:COTA/L
Mailing Address - Street 1:503 GIANT CITY RD
Mailing Address - Street 2:
Mailing Address - City:MONTICELLO
Mailing Address - State:IL
Mailing Address - Zip Code:61856-8189
Mailing Address - Country:US
Mailing Address - Phone:217-454-0612
Mailing Address - Fax:
Practice Address - Street 1:4112 FIELDSTONE RD
Practice Address - Street 2:SUITE B
Practice Address - City:CHAMPAIGN
Practice Address - State:IL
Practice Address - Zip Code:61822
Practice Address - Country:US
Practice Address - Phone:888-308-3728
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-07-18
Last Update Date:2019-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL057004851224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant