MEDICARE: EMILY VANDENBUSH MOT, 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	121288	TX

General Provider Information

NPI Number	:	1609541325
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	EMILY VANDENBUSH MOT, OTR/L

Provider Business Mailing Address
First Line	:	1111 ELIZABETH BLVD
Second Line	:
City	:	GRANBURY
State	:	TX
Zip	:	76048-2311
Country	:	US
Telephone Number	:	262-951-0550
Fax Number	:

Provider Business Practice Location Address
First Line	:	1429 CLEAR LAKE RD STE 200
Second Line	:
City	:	WEATHERFORD
State	:	TX
Zip	:	76086-8801
Country	:	US
Telephone Number	:	682-231-1720
Fax Number	:

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

Provider Enumeration Date	:	08/13/2021
Last Update Date	:	08/13/2021

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