=====================================================
General NPI Number Information
=====================================================
NPI Number | 1982165916
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | KELLY ELIZABETH MUSICK
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/31/2019
-----------------------------------------------------
Last Update Date | 03/31/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 755 OHLTOWN RD
-----------------------------------------------------
City | AUSTINTOWN
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 44515-1075
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 339-505-0144
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3283 NILES CORTLAND RD NE
-----------------------------------------------------
City | CORTLAND
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 44410-1739
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 330-718-4748
-----------------------------------------------------
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 | OT010301
-----------------------------------------------------
License Number State | OH
-----------------------------------------------------