MEDICARE: JOAN CARLSONMILLER V

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	000016	OH

General Provider Information

NPI Number	:	1235267485
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JOAN CARLSONMILLER V

Provider Business Mailing Address
First Line	:	633 TOLLIS PKWY
Second Line	:
City	:	BROADVIEW HTS
State	:	OH
Zip	:	44147-1811
Country	:	US
Telephone Number	:	440-582-3563
Fax Number	:

Provider Business Practice Location Address
First Line	:	633 TOLLIS PKWY
Second Line	:
City	:	BROADVIEW HTS
State	:	OH
Zip	:	44147-1811
Country	:	US
Telephone Number	:	440-582-3563
Fax Number	:

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

Provider Enumeration Date	:	03/01/2007
Last Update Date	:	07/08/2007

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