Provider Demographics
NPI:1972132991
Name:RAUCH, CLINTON DAVID (MS, OTR/L)
Entity Type:Individual
Prefix:
First Name:CLINTON
Middle Name:DAVID
Last Name:RAUCH
Suffix:
Gender:M
Credentials:MS, OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1700 QUARTZ LN
Mailing Address - Street 2:
Mailing Address - City:INGRAHAM
Mailing Address - State:IL
Mailing Address - Zip Code:62434-3014
Mailing Address - Country:US
Mailing Address - Phone:618-843-2694
Mailing Address - Fax:
Practice Address - Street 1:800 E LOCUST ST
Practice Address - Street 2:
Practice Address - City:OLNEY
Practice Address - State:IL
Practice Address - Zip Code:62450-2553
Practice Address - Country:US
Practice Address - Phone:618-395-7340
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-04-02
Last Update Date:2020-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL056012847225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist