MEDICARE: MRS. AUTUMN MICHELLE LONG MALONE OTR/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	3580	TN

General Provider Information

NPI Number	:	1477810729
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. AUTUMN MICHELLE LONG MALONE OTR/L

Provider Business Mailing Address
First Line	:	801 E MCKEE ST
Second Line	:
City	:	GREENEVILLE
State	:	TN
Zip	:	37743-6010
Country	:	US
Telephone Number	:	423-638-9226
Fax Number	:

Provider Business Practice Location Address
First Line	:	801 E MCKEE ST
Second Line	:
City	:	GREENEVILLE
State	:	TN
Zip	:	37743-6010
Country	:	US
Telephone Number	:	423-638-9226
Fax Number	:

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

Provider Enumeration Date	:	04/11/2012
Last Update Date	:	04/11/2012

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