=====================================================
General NPI Number Information
=====================================================
NPI Number | 1366876286
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JULIE RODGERS BOYETT
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/27/2013
-----------------------------------------------------
Last Update Date | 08/27/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 117 E 2ND ST
-----------------------------------------------------
City | HOPE
-----------------------------------------------------
State | AR
-----------------------------------------------------
Zip | 71801-4402
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 870-904-9731
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 173
-----------------------------------------------------
City | TAYLOR
-----------------------------------------------------
State | AR
-----------------------------------------------------
Zip | 71861-0173
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 870-904-9731
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 224Z00000X
-----------------------------------------------------
Taxonomy Name | Occupational Therapy Assistant
-----------------------------------------------------
License Number | OT-A469
-----------------------------------------------------
License Number State | AR
-----------------------------------------------------