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General NPI Number Information
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NPI Number | 1407632474
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Entity Type | Organization
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Legal Business Name | PEDEN PEDIATRIC THERAPY, LLC
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Dates
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Enumeration Date | 09/06/2023
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Last Update Date | 09/06/2023
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Provider Practice Location Address
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Address Line | 2363 TUTOR RD
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City | ECRU
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State | MS
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Zip | 38841-9106
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Country | US
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Telephone | 601-480-8741
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 236
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City | ECRU
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State | MS
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Zip | 38841-0236
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | MRS. MALLORY VANCE PEDEN
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Credential | OTR/L
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Telephone | 601-480-8741
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 225X00000X
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Taxonomy Name | Occupational Therapist
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License Number |
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License Number State |
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