Provider Demographics
NPI:1982849154
Name:EDMUND, MARIAN LYNN (COTA/L)
Entity Type:Individual
Prefix:MS
First Name:MARIAN
Middle Name:LYNN
Last Name:EDMUND
Suffix:
Gender:F
Credentials:COTA/L
Other - Prefix:MRS
Other - First Name:MARIAN
Other - Middle Name:LYNN
Other - Last Name:CLARK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:COTA/L
Mailing Address - Street 1:407 S OAKWOOD AVE
Mailing Address - Street 2:
Mailing Address - City:GENESEO
Mailing Address - State:IL
Mailing Address - Zip Code:61254-1567
Mailing Address - Country:US
Mailing Address - Phone:309-507-1714
Mailing Address - Fax:
Practice Address - Street 1:7300 34TH AVE
Practice Address - Street 2:
Practice Address - City:MOLINE
Practice Address - State:IL
Practice Address - Zip Code:61265-5842
Practice Address - Country:US
Practice Address - Phone:309-792-5940
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-12-02
Last Update Date:2008-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL057.002193224Z00000X
IA00744224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant