Provider Demographics
NPI:1487192415
Name:MCCRACKEN, KERRY M (BS,OTR/L)
Entity type:Individual
Prefix:
First Name:KERRY
Middle Name:M
Last Name:MCCRACKEN
Suffix:
Gender:F
Credentials:BS,OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4450 48TH AVENUE CT
Mailing Address - Street 2:
Mailing Address - City:ROCK ISLAND
Mailing Address - State:IL
Mailing Address - Zip Code:61201-9213
Mailing Address - Country:US
Mailing Address - Phone:309-558-0145
Mailing Address - Fax:309-558-0149
Practice Address - Street 1:4450 48TH AVENUE CT
Practice Address - Street 2:
Practice Address - City:ROCK ISLAND
Practice Address - State:IL
Practice Address - Zip Code:61201-9213
Practice Address - Country:US
Practice Address - Phone:309-558-0145
Practice Address - Fax:309-558-0149
Is Sole Proprietor?:No
Enumeration Date:2017-02-10
Last Update Date:2017-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL056.003431225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist