MEDICARE: KELSEY JOHNSON-UPSHAW 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	122855	TX

General Provider Information

NPI Number	:	1629703293
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KELSEY JOHNSON-UPSHAW OT

Provider Business Mailing Address
First Line	:	601 TABASCO TRL
Second Line	:
City	:	ARLINGTON
State	:	TX
Zip	:	76002-4213
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	601 TABASCO TRL
Second Line	:
City	:	ARLINGTON
State	:	TX
Zip	:	76002-4213
Country	:	US
Telephone Number	:	972-207-9478
Fax Number	:

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

Provider Enumeration Date	:	07/19/2022
Last Update Date	:	07/19/2022

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