Individual
DIANNE M TENNANT RUCKER
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
F
Credential
OTRL
Contact information
Practice address
905 N RIVERVIEW LN, MAHOMET, IL 61853-9768
(217) 621-5429
(866) 267-2080
Mailing address
905 N RIVERVIEW LN, MAHOMET, IL 61853-9768
(217) 621-5429
(866) 267-2080
Taxonomy
Speciality
Code
Description
License number
State
225X00000X
Occupational Therapist
Primary
DM58211298P
IL
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
0001032002
BLUE CROSS BLUE SHEILD
IL
05
—
371389210
—
IL
01
—
DM58211298P
IL OT LICNESE NUMBER
IL
Enumeration date
01/22/2007
Last updated
07/09/2007
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