Provider Demographics
NPI:1336748730
Name:RAU, MORGAN NICOLE
Entity type:Individual
Prefix:
First Name:MORGAN
Middle Name:NICOLE
Last Name:RAU
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:471 W TERRA COTTA AVE
Mailing Address - Street 2:
Mailing Address - City:CRYSTAL LAKE
Mailing Address - State:IL
Mailing Address - Zip Code:60014-3434
Mailing Address - Country:US
Mailing Address - Phone:815-455-0550
Mailing Address - Fax:
Practice Address - Street 1:471 W TERRA COTTA AVE
Practice Address - Street 2:
Practice Address - City:CRYSTAL LAKE
Practice Address - State:IL
Practice Address - Zip Code:60014-3434
Practice Address - Country:US
Practice Address - Phone:815-455-0550
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-10-19
Last Update Date:2020-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI5489-27224Z00000X
IL057.004886224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant