Provider Demographics
NPI:1851460778
Name:WHITE- KING, MISTY LEIGH (OCCUPATIONAL THERAPY)
Entity Type:Individual
Prefix:MRS
First Name:MISTY
Middle Name:LEIGH
Last Name:WHITE- KING
Suffix:
Gender:F
Credentials:OCCUPATIONAL THERAPY
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:399 BERLIN RD
Mailing Address - Street 2:
Mailing Address - City:NEW BERLIN
Mailing Address - State:IL
Mailing Address - Zip Code:62670-4541
Mailing Address - Country:US
Mailing Address - Phone:217-652-0146
Mailing Address - Fax:
Practice Address - Street 1:399 BERLIN RD
Practice Address - Street 2:
Practice Address - City:NEW BERLIN
Practice Address - State:IL
Practice Address - Zip Code:62670-7957
Practice Address - Country:US
Practice Address - Phone:217-652-0146
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-07
Last Update Date:2015-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL056005570225X00000X, 332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL8432032OtherBCBS PROVIDER NUMBER