=====================================================
General NPI Number Information
=====================================================
NPI Number | 1568659290
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | SUSAN M. PROVOST-DANNER OTR
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/26/2007
-----------------------------------------------------
Last Update Date | 12/09/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1102 WINKLER AVE
-----------------------------------------------------
City | KILLEEN
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 76542-6249
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 254-634-8505
-----------------------------------------------------
Fax | 254-519-3477
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 8621 MOUNTAIN DR
-----------------------------------------------------
City | SALADO
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 76571-5109
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 254-947-5431
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
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 | OT004598
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 225XP0200X
-----------------------------------------------------
Taxonomy Name | Pediatric Occupational Therapist
-----------------------------------------------------
License Number | 106402
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------