Healthcare Provider Details

I. General information

NPI: 1982776183
Provider Name (Legal Business Name): PENNY ROGERS OT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/14/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

305 ELLIS ST
CARTHAGE MS
39051-3808
US

IV. Provider business mailing address

1694 HIGHWAY 35 S
CARTHAGE MS
39051-6058
US

V. Phone/Fax

Practice location:
  • Phone: 601-267-3247
  • Fax: 601-267-0209
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License NumberOT0489
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: