Provider Demographics
NPI:1437907151
Name:KEITH, SOPHIA A (OTR/L)
Entity type:Individual
Prefix:
First Name:SOPHIA
Middle Name:A
Last Name:KEITH
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:313 CARRIE LN
Mailing Address - Street 2:
Mailing Address - City:CHATHAM
Mailing Address - State:IL
Mailing Address - Zip Code:62629-1511
Mailing Address - Country:US
Mailing Address - Phone:618-357-0953
Mailing Address - Fax:
Practice Address - Street 1:4101 W ILES AVE
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:IL
Practice Address - Zip Code:62711-7051
Practice Address - Country:US
Practice Address - Phone:217-793-9429
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-05-08
Last Update Date:2024-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL056.016003225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist