Healthcare Provider Details

I. General information

NPI: 1275867319
Provider Name (Legal Business Name): TYNISA LA'KEISHIRR BAYLES MOT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/22/2009
Last Update Date: 07/16/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15 RANDALL HILL RD
SPRINGFIELD VT
05156-9317
US

IV. Provider business mailing address

PO BOX 894
SPRINGFIELD VT
05156-0894
US

V. Phone/Fax

Practice location:
  • Phone: 832-247-7700
  • Fax:
Mailing address:
  • Phone: 832-247-7700
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225XP0200X
TaxonomyPediatric Occupational Therapist
License Number072.0049825
License Number StateVT
# 2
Primary TaxonomyN
Taxonomy Code225XP0200X
TaxonomyPediatric Occupational Therapist
License Number2076
License Number StateNH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: