Provider Demographics
NPI:1770837122
Name:TICER, ROSEMARY LYNN (COTA/L)
Entity Type:Individual
Prefix:
First Name:ROSEMARY
Middle Name:LYNN
Last Name:TICER
Suffix:
Gender:F
Credentials:COTA/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:306 W MILL ST
Mailing Address - Street 2:
Mailing Address - City:CARBONDALE
Mailing Address - State:IL
Mailing Address - Zip Code:62901-2727
Mailing Address - Country:US
Mailing Address - Phone:618-529-2922
Mailing Address - Fax:618-529-0102
Practice Address - Street 1:306 W MILL ST
Practice Address - Street 2:
Practice Address - City:CARBONDALE
Practice Address - State:IL
Practice Address - Zip Code:62901-2727
Practice Address - Country:US
Practice Address - Phone:618-529-2922
Practice Address - Fax:618-529-0102
Is Sole Proprietor?:No
Enumeration Date:2012-11-07
Last Update Date:2012-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL057.001356224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant