Healthcare Provider Details

I. General information

NPI: 1184243750
Provider Name (Legal Business Name): MIRIAM KENNETZ MOTR/L
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/13/2020
Last Update Date: 04/13/2020
Certification Date: 04/13/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

600 JEFFERSON AVE
MEMPHIS TN
38105-4934
US

IV. Provider business mailing address

173 SAINT AGNES DR
MEMPHIS TN
38112-4716
US

V. Phone/Fax

Practice location:
  • Phone: 901-287-4900
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225XP0200X
TaxonomyPediatric Occupational Therapist
License Number6034
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: