Healthcare Provider Details

I. General information

NPI: 1639614514
Provider Name (Legal Business Name): ANDREW CARTLIDGE
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/30/2016
Last Update Date: 12/30/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3261 HIGHWAY 49
COLLINS MS
39428-3876
US

IV. Provider business mailing address

4109 HIGHWAY 98 W
SUMMIT MS
39666-9132
US

V. Phone/Fax

Practice location:
  • Phone: 601-765-9390
  • Fax:
Mailing address:
  • Phone: 601-276-3900
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code224Z00000X
TaxonomyOccupational Therapy Assistant
License NumberTA2215
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: