Healthcare Provider Details

I. General information

NPI: 1760298400
Provider Name (Legal Business Name): CAELEY MYA CORLEY COTA/L
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/07/2024
Last Update Date: 06/01/2026
Certification Date: 06/01/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5 E SOUTH ST
HERNANDO MS
38632-2216
US

IV. Provider business mailing address

3295 HUNTER RD N
SOUTHAVEN MS
38672-8719
US

V. Phone/Fax

Practice location:
  • Phone: 662-429-5271
  • Fax:
Mailing address:
  • Phone: 225-253-0317
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code224Z00000X
TaxonomyOccupational Therapy Assistant
License Number4093
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: