MEDICARE: MRS. CONSTANCE HOPE MARSHALL MOTR/L

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225X00000X	Occupational Therapist	OT2573	MS
2	225XG0600X	Gerontology Occupational Therapist	OT2573	MS

General Provider Information

NPI Number	:	1013306729
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. CONSTANCE HOPE MARSHALL MOTR/L

Provider Business Mailing Address
First Line	:	801 JORDAN SUMRALL RD
Second Line	:
City	:	BUCKATUNNA
State	:	MS
Zip	:	39322-9630
Country	:	US
Telephone Number	:	601-410-0620
Fax Number	:

Provider Business Practice Location Address
First Line	:	1036 WEST DR
Second Line	:
City	:	LAUREL
State	:	MS
Zip	:	39440-4706
Country	:	US
Telephone Number	:	601-425-3191
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/19/2015
Last Update Date	:	01/19/2015

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