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General NPI Number Information
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NPI Number | 1497391106
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Entity Type | Individual
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Provider Name | TAKISHA KAYON SANDERS OTR/L
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Gender | Female
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Dates
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Enumeration Date | 11/18/2019
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Last Update Date | 08/09/2022
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Provider Practice Location Address
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Address Line | 5130 WEDGEWOOD DR
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City | OLIVE BRANCH
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State | MS
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Zip | 38654-6616
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Country | US
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Telephone | 912-308-8143
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Fax |
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Provider Business Mailing Address
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Address Line | 4744 WE ROSS PKWY APT 50-201
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City | SOUTHAVEN
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State | MS
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Zip | 38671-7003
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Country | US
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Telephone | 912-308-8143
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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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 | OT3722
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License Number State | MS
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