MEDICARE: MIGHTY OAK THERAPY SERVICES PLLC

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

General Provider Information

NPI Number	:	1578154167
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MIGHTY OAK THERAPY SERVICES PLLC

Provider Business Mailing Address
First Line	:	672 LAKEWOOD RD
Second Line	:
City	:	TRAVERSE CITY
State	:	MI
Zip	:	49685-8872
Country	:	US
Telephone Number	:	231-392-6420
Fax Number	:

Provider Business Practice Location Address
First Line	:	672 LAKEWOOD RD
Second Line	:
City	:	TRAVERSE CITY
State	:	MI
Zip	:	49685-8872
Country	:	US
Telephone Number	:	231-392-6420
Fax Number	:	231-346-5986

Authorized Official
Title or Position	:	OWNER
Name	:	JODI LEE CARROLL
Credential	:	MS, OTR/L
Telephone Number	:	231-392-6420

Provider Enumeration Date	:	01/27/2021
Last Update Date	:	01/27/2021

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