=====================================================
General NPI Number Information
=====================================================
NPI Number | 1306564703
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | KRISTA PORTEOUS
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/22/2022
-----------------------------------------------------
Last Update Date | 08/22/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 809 UNIVERSITY BLVD E
-----------------------------------------------------
City | TUSCALOOSA
-----------------------------------------------------
State | AL
-----------------------------------------------------
Zip | 35401-2029
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 205-759-7111
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 15947 HIGHWAY 216
-----------------------------------------------------
City | BROOKWOOD
-----------------------------------------------------
State | AL
-----------------------------------------------------
Zip | 35444-3714
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 205-242-9806
-----------------------------------------------------
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 | 4692
-----------------------------------------------------
License Number State | AL
-----------------------------------------------------