=====================================================
General NPI Number Information
=====================================================
NPI Number | 1376273144
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | SHELBY RAE SWEETS OTD, OTR/L
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/14/2022
-----------------------------------------------------
Last Update Date | 05/12/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 301 S GALLAHER VIEW RD STE 105
-----------------------------------------------------
City | KNOXVILLE
-----------------------------------------------------
State | TN
-----------------------------------------------------
Zip | 37919-5302
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 865-328-7410
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 90 HOWARD DR
-----------------------------------------------------
City | SHELBYVILLE
-----------------------------------------------------
State | KY
-----------------------------------------------------
Zip | 40065-8138
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 865-809-9123
-----------------------------------------------------
Fax | 502-805-1511
-----------------------------------------------------
=====================================================
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 | 7292
-----------------------------------------------------
License Number State | TN
-----------------------------------------------------