Provider Demographics
NPI:1316091036
Name:TENNANT RUCKER, DIANNE M (OTRL)
Entity type:Individual
Prefix:
First Name:DIANNE
Middle Name:M
Last Name:TENNANT RUCKER
Suffix:
Gender:F
Credentials:OTRL
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:905 N RIVERVIEW LN
Mailing Address - Street 2:
Mailing Address - City:MAHOMET
Mailing Address - State:IL
Mailing Address - Zip Code:61853-9768
Mailing Address - Country:US
Mailing Address - Phone:217-621-5429
Mailing Address - Fax:866-267-2080
Practice Address - Street 1:905 N RIVERVIEW LN
Practice Address - Street 2:
Practice Address - City:MAHOMET
Practice Address - State:IL
Practice Address - Zip Code:61853-9768
Practice Address - Country:US
Practice Address - Phone:217-621-5429
Practice Address - Fax:866-267-2080
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-22
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ILDM58211298P225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL371389210Medicaid
ILDM58211298POtherIL OT LICNESE NUMBER
IL0001032002OtherBLUE CROSS BLUE SHEILD
IL371389210Medicaid