Provider Demographics
NPI:1720284151
Name:GOLLADAY, REBECCA L (OTR-L)
Entity Type:Individual
Prefix:
First Name:REBECCA
Middle Name:L
Last Name:GOLLADAY
Suffix:
Gender:F
Credentials:OTR-L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:212 EDWARDS DR
Mailing Address - Street 2:
Mailing Address - City:NORMAL
Mailing Address - State:IL
Mailing Address - Zip Code:61761-2334
Mailing Address - Country:US
Mailing Address - Phone:309-824-7417
Mailing Address - Fax:
Practice Address - Street 1:212 EDWARDS DR
Practice Address - Street 2:
Practice Address - City:NORMAL
Practice Address - State:IL
Practice Address - Zip Code:61761-2334
Practice Address - Country:US
Practice Address - Phone:309-824-7417
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-06-22
Last Update Date:2017-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC5657225XP0200X
IL056006902225XP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatrics