Basic Information
Provider Information
NPI: 1033556956
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: FIELDS
FirstName: AUDREY
MiddleName: MARIE
NamePrefix:  
NameSuffix:  
Credential: MS, MOT, OTR/L
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: 21393 BRAMBLE DR
Address2:  
City: FRANKFORT
State: IL
PostalCode: 604239463
CountryCode: US
TelephoneNumber: 8159221804
FaxNumber:  
Practice Location
Address1: 21393 BRAMBLE DR
Address2:  
City: FRANKFORT
State: IL
PostalCode: 604239463
CountryCode: US
TelephoneNumber: 8159221804
FaxNumber:  
Other Information
ProviderEnumerationDate: 06/01/2013
LastUpdateDate: 06/01/2013
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: F
AuthorizedOfficialLastName:  
AuthorizedOfficialFirstName:  
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition:  
AuthorizedOfficialTelephone:  
IsSoleProprietor: Y
IsOrganizationSubpart:  
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
225XP0200X056009727ILY Respiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatrics

No ID Information.


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