MEDICARE: KELLIE SEDGLEY LEWIS OTRL

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225X00000X	Occupational Therapist	4042	NC

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	126YC	OTHER	NC	BCBS

General Provider Information

NPI Number	:	1043344278
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KELLIE SEDGLEY LEWIS OTRL

Provider Business Mailing Address
First Line	:	2405 BARDAY DOWNS LN
Second Line	:
City	:	RALEIGH
State	:	NC
Zip	:	27606-4005
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	319 CHAPANOKE RD STE 101
Second Line	:
City	:	RALEIGH
State	:	NC
Zip	:	27603-3433
Country	:	US
Telephone Number	:	919-662-4600
Fax Number	:	919-662-4733

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/16/2007
Last Update Date	:	07/08/2007

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