=====================================================
General NPI Number Information
=====================================================
NPI Number | 1912161316
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | KELLY JEAN TOBIN
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/15/2008
-----------------------------------------------------
Last Update Date | 07/15/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1330 W 26TH ST
-----------------------------------------------------
City | ERIE
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 16508-1402
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 814-459-9300
-----------------------------------------------------
Fax | 814-454-7780
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 7231 STATION RD
-----------------------------------------------------
City | ERIE
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 16510-4850
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 814-899-0906
-----------------------------------------------------
Fax | 814-454-7780
-----------------------------------------------------
=====================================================
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 | OC005141L
-----------------------------------------------------
License Number State | PA
-----------------------------------------------------