Healthcare Provider Details

I. General information

NPI: 1770716615
Provider Name (Legal Business Name): LORRAINE M STREET OTR/L
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/26/2009
Last Update Date: 08/26/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4500 I 55 N SUITE 291, HIGHLAND VILLAGE
JACKSON MS
39211-5930
US

IV. Provider business mailing address

4500 I 55 N SUITE 291, HIGHLAND VILLAGE
JACKSON MS
39211-5930
US

V. Phone/Fax

Practice location:
  • Phone: 601-362-0859
  • Fax: 601-362-0870
Mailing address:
  • Phone: 601-362-0859
  • Fax: 601-362-0870

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License NumberOT0074
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: