=====================================================
General NPI Number Information
=====================================================
NPI Number | 1609175439
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | GLENDA LOIS BLOOD OTR/L
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/18/2011
-----------------------------------------------------
Last Update Date | 03/18/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 395 RIGHT FORK HAMILTON RDG
-----------------------------------------------------
City | BEATTYVILLE
-----------------------------------------------------
State | KY
-----------------------------------------------------
Zip | 41311-8724
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 606-464-9132
-----------------------------------------------------
Fax | 606-464-9133
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 395 RIGHT FORK HAMILTON RDG
-----------------------------------------------------
City | BEATTYVILLE
-----------------------------------------------------
State | KY
-----------------------------------------------------
Zip | 41311-8724
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 606-464-9132
-----------------------------------------------------
Fax | 606-464-9133
-----------------------------------------------------
=====================================================
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 | R1200
-----------------------------------------------------
License Number State | KY
-----------------------------------------------------