=====================================================
General NPI Number Information
=====================================================
NPI Number | 1912532250
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | TAMMY RENAE MARION
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/06/2020
-----------------------------------------------------
Last Update Date | 03/06/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2801 US HIGHWAY 25 E STE 98
-----------------------------------------------------
City | MIDDLESBORO
-----------------------------------------------------
State | KY
-----------------------------------------------------
Zip | 40965-2075
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 606-545-2631
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 843
-----------------------------------------------------
City | BARBOURVILLE
-----------------------------------------------------
State | KY
-----------------------------------------------------
Zip | 40906-0843
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 606-627-3280
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 222Q00000X
-----------------------------------------------------
Taxonomy Name | Developmental Therapist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------