Provider Demographics
NPI:1922185834
Name:ILLINGWORTH, KATHERINE (OTR)
Entity Type:Individual
Prefix:
First Name:KATHERINE
Middle Name:
Last Name:ILLINGWORTH
Suffix:
Gender:F
Credentials:OTR
Other - Prefix:MISS
Other - First Name:KATHERINE
Other - Middle Name:
Other - Last Name:RAY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:11230 CORNELL PARK DR
Mailing Address - Street 2:
Mailing Address - City:BLUE ASH
Mailing Address - State:OH
Mailing Address - Zip Code:45242-1825
Mailing Address - Country:US
Mailing Address - Phone:513-880-6800
Mailing Address - Fax:
Practice Address - Street 1:11230 CORNELL PARK DR
Practice Address - Street 2:
Practice Address - City:BLUE ASH
Practice Address - State:OH
Practice Address - Zip Code:45242-1825
Practice Address - Country:US
Practice Address - Phone:513-880-6800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-01
Last Update Date:2020-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN31004256A225X00000X
OHOT009156225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200807660Medicaid
OH2187155Medicaid
IN200689210OtherFIRST STEPS PROVIDER
OH2187155Medicaid
IN200807660Medicaid