=====================================================
General NPI Number Information
=====================================================
NPI Number | 1255958872
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | KODY MORRIS
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/30/2020
-----------------------------------------------------
Last Update Date | 06/30/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 515 FORREST PARK WAY
-----------------------------------------------------
City | GREENWOOD
-----------------------------------------------------
State | AR
-----------------------------------------------------
Zip | 72936-5955
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 479-996-5078
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 501 LEDANNA DR
-----------------------------------------------------
City | VAN BUREN
-----------------------------------------------------
State | AR
-----------------------------------------------------
Zip | 72956-6666
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 479-222-3344
-----------------------------------------------------
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 | OTR2524
-----------------------------------------------------
License Number State | AR
-----------------------------------------------------