Healthcare Provider Details

I. General information

NPI: 1356487417
Provider Name (Legal Business Name): CAROLYN COMBS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/29/2007
Last Update Date: 04/13/2023
Certification Date: 04/13/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

22864 PERIMETER LN.
LEBANON MS
65536
US

IV. Provider business mailing address

6379 S RIVULET CT
SPRINGFIELD MO
65810-3106
US

V. Phone/Fax

Practice location:
  • Phone: 417-532-6528
  • Fax:
Mailing address:
  • Phone: 417-880-0461
  • Fax: 417-725-5915

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: