=====================================================
General NPI Number Information
=====================================================
NPI Number | 1235462847
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | AYRES BALTZELL MSOTR/L
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/14/2009
-----------------------------------------------------
Last Update Date | 02/16/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 517 CLAY ST
-----------------------------------------------------
City | HENDERSON
-----------------------------------------------------
State | KY
-----------------------------------------------------
Zip | 42420-3623
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 812-449-3652
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 517 CLAY ST
-----------------------------------------------------
City | HENDERSON
-----------------------------------------------------
State | KY
-----------------------------------------------------
Zip | 42420-3623
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 812-449-3652
-----------------------------------------------------
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 | R4352
-----------------------------------------------------
License Number State | KY
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 225X00000X
-----------------------------------------------------
Taxonomy Name | Occupational Therapist
-----------------------------------------------------
License Number | 31005009A
-----------------------------------------------------
License Number State | IN
-----------------------------------------------------