Provider Demographics
NPI:1700351814
Name:EDWARDS, KATIE C
Entity Type:Individual
Prefix:
First Name:KATIE
Middle Name:C
Last Name:EDWARDS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2217 N 5TH ST
Mailing Address - Street 2:
Mailing Address - City:CLINTON
Mailing Address - State:IA
Mailing Address - Zip Code:52732-2149
Mailing Address - Country:US
Mailing Address - Phone:563-321-1901
Mailing Address - Fax:
Practice Address - Street 1:308 S 2ND ST
Practice Address - Street 2:
Practice Address - City:WALNUT
Practice Address - State:IL
Practice Address - Zip Code:61376-9364
Practice Address - Country:US
Practice Address - Phone:815-379-2131
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-10-05
Last Update Date:2021-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA089435224Z00000X
IL057004856224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL057004856OtherILLINOIS DEPARTMENT OF FINANCIAL AND PROFESSIONAL REGULATION