=====================================================
General NPI Number Information
=====================================================
NPI Number | 1407385552
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CAROLINA OCCUPATIONAL THERAPY SERVICES
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/11/2017
-----------------------------------------------------
Last Update Date | 07/21/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 112 LONG POND DR
-----------------------------------------------------
City | KING
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 27021-8807
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 336-608-0555
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 112 LONG POND DR
-----------------------------------------------------
City | KING
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 27021-8807
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 336-608-0555
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OCCUPATIONAL THERAPIST
-----------------------------------------------------
Name | KELLI B CROSS
-----------------------------------------------------
Credential | MOTR/L
-----------------------------------------------------
Telephone | 336-608-0555
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225XP0200X
-----------------------------------------------------
Taxonomy Name | Pediatric Occupational Therapist
-----------------------------------------------------
License Number | 6279
-----------------------------------------------------
License Number State | NC
-----------------------------------------------------