Provider Demographics
NPI:1750657581
Name:EATOCK, KATIE JOANNE (OT)
Entity Type:Individual
Prefix:
First Name:KATIE
Middle Name:JOANNE
Last Name:EATOCK
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 1:2213 GRAND AVE
Mailing Address - Street 2:
Mailing Address - City:DES MOINES
Mailing Address - State:IA
Mailing Address - Zip Code:50312-5305
Mailing Address - Country:US
Mailing Address - Phone:515-237-3974
Mailing Address - Fax:515-883-2692
Practice Address - Street 1:758 216TH DR
Practice Address - Street 2:
Practice Address - City:OGDEN
Practice Address - State:IA
Practice Address - Zip Code:50212-7520
Practice Address - Country:US
Practice Address - Phone:515-275-4003
Practice Address - Fax:515-275-4122
Is Sole Proprietor?:No
Enumeration Date:2012-03-27
Last Update Date:2012-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA001982225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IAIN PROCESSMedicaid
IAIN PROCESSMedicare PIN