Provider Demographics
NPI:1871103010
Name:EGGENBERGER, CALVIN JOHN (OTR/L)
Entity type:Individual
Prefix:
First Name:CALVIN
Middle Name:JOHN
Last Name:EGGENBERGER
Suffix:
Gender:M
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 1:1822 GLENBRIDGE RD
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IL
Mailing Address - Zip Code:61704-8769
Mailing Address - Country:US
Mailing Address - Phone:619-735-6105
Mailing Address - Fax:
Practice Address - Street 1:1200 E COLLEGE AVE
Practice Address - Street 2:
Practice Address - City:NORMAL
Practice Address - State:IL
Practice Address - Zip Code:61761-3100
Practice Address - Country:US
Practice Address - Phone:309-533-7673
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-08-03
Last Update Date:2020-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL056.013673225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist