Provider Demographics
NPI:1932739836
Name:BOHM, VANESSA K (COTA)
Entity Type:Individual
Prefix:
First Name:VANESSA
Middle Name:K
Last Name:BOHM
Suffix:
Gender:F
Credentials:COTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:22918 N MAHER RD
Mailing Address - Street 2:
Mailing Address - City:PRINCEVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:61559-9429
Mailing Address - Country:US
Mailing Address - Phone:309-360-2327
Mailing Address - Fax:
Practice Address - Street 1:1028 W HILLCREST DR
Practice Address - Street 2:
Practice Address - City:CHILLICOTHE
Practice Address - State:IL
Practice Address - Zip Code:61523-2258
Practice Address - Country:US
Practice Address - Phone:309-274-2194
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-01-19
Last Update Date:2020-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL057005267224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant