Provider Demographics
NPI:1801138532
Name:RISNER, BETH A (OT)
Entity type:Individual
Prefix:
First Name:BETH
Middle Name:A
Last Name:RISNER
Suffix:
Gender:F
Credentials:OT
Other - Prefix:
Other - First Name:BETH
Other - Middle Name:A
Other - Last Name:WARKENTIEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:790 REMINGTON BLVD
Mailing Address - Street 2:
Mailing Address - City:BOLINGBROOK
Mailing Address - State:IL
Mailing Address - Zip Code:60440-4909
Mailing Address - Country:US
Mailing Address - Phone:630-296-2223
Mailing Address - Fax:630-759-9510
Practice Address - Street 1:8455 BROADWAY
Practice Address - Street 2:
Practice Address - City:MERRILLVILLE
Practice Address - State:IN
Practice Address - Zip Code:46410-6220
Practice Address - Country:US
Practice Address - Phone:219-769-7211
Practice Address - Fax:219-769-7236
Is Sole Proprietor?:No
Enumeration Date:2013-03-20
Last Update Date:2014-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN31005453A225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN487210006Medicare PIN
IN555850027Medicare PIN