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General NPI Number Information
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NPI Number | 1134883242
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Entity Type | Individual
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Provider Name | MACKENZIE ALYSE GULLEY MOT, LOTR
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Gender | Female
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Dates
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Enumeration Date | 10/25/2021
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Last Update Date | 10/25/2021
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Provider Practice Location Address
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Address Line | 220 PARK PL STE 201
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City | COVINGTON
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State | LA
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Zip | 70433-5267
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Country | US
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Telephone | 985-898-2999
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Fax |
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Provider Business Mailing Address
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Address Line | 720 HEAVENS DR APT 2
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City | MANDEVILLE
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State | LA
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Zip | 70471-6738
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Country | US
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Telephone | 318-393-9255
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 225X00000X
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Taxonomy Name | Occupational Therapist
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License Number | 329138
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License Number State | LA
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