Provider Demographics
NPI:1356483952
Name:OCILLOS, MIRIAM MORALES (PT)
Entity type:Individual
Prefix:
First Name:MIRIAM
Middle Name:MORALES
Last Name:OCILLOS
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1401 E STATE ST
Mailing Address - Street 2:
Mailing Address - City:ROCKFORD
Mailing Address - State:IL
Mailing Address - Zip Code:61104-2315
Mailing Address - Country:US
Mailing Address - Phone:815-968-4400
Mailing Address - Fax:
Practice Address - Street 1:1301 N ALPINE RD # 201
Practice Address - Street 2:
Practice Address - City:ROCKFORD
Practice Address - State:IL
Practice Address - Zip Code:61107-2262
Practice Address - Country:US
Practice Address - Phone:779-696-0700
Practice Address - Fax:779-696-0710
Is Sole Proprietor?:No
Enumeration Date:2007-02-12
Last Update Date:2024-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL070.014789225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist