MEDICARE: LIBERTY THERAPY, P.A.

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	100503	TX

General Provider Information

NPI Number	:	1205166063
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LIBERTY THERAPY, P.A.

Provider Business Mailing Address
First Line	:	107 NW MAIN ST
Second Line	:
City	:	ENNIS
State	:	TX
Zip	:	75119-4053
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	107 NW MAIN ST
Second Line	:
City	:	ENNIS
State	:	TX
Zip	:	75119-4053
Country	:	US
Telephone Number	:	469-641-0004
Fax Number	:

Authorized Official
Title or Position	:	PROVIDER/FACILITATOR
Name	:	MRS. DALAINE BARRON FLETCHER
Credential	:	OTR
Telephone Number	:	469-641-0004

Provider Enumeration Date	:	12/30/2009
Last Update Date	:	12/30/2009

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Directions to “LIBERTY THERAPY, P.A. ” Practice Location

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