=====================================================
General NPI Number Information
=====================================================
NPI Number | 1922759273
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | KEVA MARIE WOOD OTRL
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/18/2022
-----------------------------------------------------
Last Update Date | 01/18/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1101 S SCOTT RD
-----------------------------------------------------
City | SAINT JOHNS
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48879-8044
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 989-224-8936
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2021 SECRETARIAT LN
-----------------------------------------------------
City | SAINT JOHNS
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48879-8034
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 989-640-5309
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
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 | 5201011127
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------