=====================================================
General NPI Number Information
=====================================================
NPI Number | 1386358505
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | SHALI NICOLE DENISON OTR/L
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/11/2023
-----------------------------------------------------
Last Update Date | 01/11/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1241 VOLUNTEER PKWY STE 400
-----------------------------------------------------
City | BRISTOL
-----------------------------------------------------
State | TN
-----------------------------------------------------
Zip | 37620-4635
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 910-818-0977
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 13 PENDLETON PL
-----------------------------------------------------
City | KINGSPORT
-----------------------------------------------------
State | TN
-----------------------------------------------------
Zip | 37664-2169
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 423-736-7369
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225XP0200X
-----------------------------------------------------
Taxonomy Name | Pediatric Occupational Therapist
-----------------------------------------------------
License Number | 7291
-----------------------------------------------------
License Number State | TN
-----------------------------------------------------