=====================================================
General NPI Number Information
=====================================================
NPI Number | 1720660079
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MEGAN COLLEEN SMITH OT
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/26/2021
-----------------------------------------------------
Last Update Date | 04/20/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2363 HIGHWAY 287 N STE 205
-----------------------------------------------------
City | MANSFIELD
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 76063-7587
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 817-592-3021
-----------------------------------------------------
Fax | 888-557-1669
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4204 STONEBRIAR TRL
-----------------------------------------------------
City | MANSFIELD
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 76063-5875
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 817-592-3021
-----------------------------------------------------
Fax | 888-557-1669
-----------------------------------------------------
=====================================================
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 | 116807
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------