MEDICARE: PHILLIP D CARPENTER OT

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	Z11082	LA

General Provider Information

NPI Number	:	1629275847
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	PHILLIP D CARPENTER OT

Provider Business Mailing Address
First Line	:	1418 CROSS LAKE CIR
Second Line	:
City	:	SHREVEPORT
State	:	LA
Zip	:	71109-1935
Country	:	US
Telephone Number	:	318-635-2044
Fax Number	:

Provider Business Practice Location Address
First Line	:	1418 CROSS LAKE CIRLE
Second Line	:
City	:	SHREVEPORT
State	:	LA
Zip	:	71109-1935
Country	:	US
Telephone Number	:	318-635-2044
Fax Number	:

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

Provider Enumeration Date	:	06/29/2007
Last Update Date	:	07/08/2007

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