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General NPI Number Information
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NPI Number | 1619481082
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Entity Type | Organization
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Legal Business Name | LEANN CARGILE , OTR, LLC
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Dates
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Enumeration Date | 11/21/2017
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Last Update Date | 11/21/2017
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Provider Practice Location Address
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Address Line | 615 S BROADWAY AVE STE 103
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City | TYLER
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State | TX
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Zip | 75701-1668
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Country | US
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Telephone | 903-258-0807
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Fax | 903-686-1211
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Provider Business Mailing Address
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Address Line | 11231 MARSH WREN CIR
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City | FLINT
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State | TX
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Zip | 75762-8739
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Country | US
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Telephone | 903-258-0807
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Fax | 903-686-1211
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Authorized Official
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Title or Position | OWNER
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Name | LEANN CARGILE
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Credential | OTR
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Telephone | 903-258-0807
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 225XP0200X
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Taxonomy Name | Pediatric Occupational Therapist
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License Number | 106193
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License Number State | TX
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