=====================================================
General NPI Number Information
=====================================================
NPI Number | 1174095012
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | KELLY MASON OTR/L
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/17/2018
-----------------------------------------------------
Last Update Date | 12/17/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2832 E FLAMINGO RD
-----------------------------------------------------
City | LAS VEGAS
-----------------------------------------------------
State | NV
-----------------------------------------------------
Zip | 89121-5205
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 525-799-5252
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1383 RUBY SKY CT
-----------------------------------------------------
City | HENDERSON
-----------------------------------------------------
State | NV
-----------------------------------------------------
Zip | 89052-3137
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 702-417-7913
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225X00000X
-----------------------------------------------------
Taxonomy Name | Occupational Therapist
-----------------------------------------------------
License Number | OT-2069
-----------------------------------------------------
License Number State | NV
-----------------------------------------------------