MEDICARE: KAYLA MOGG OTD, OTR/L

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	225XP0200X	Pediatric Occupational Therapist
2	225X00000X	Occupational Therapist	31007211A	IN

General Provider Information

NPI Number	:	1053921478
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KAYLA MOGG OTD, OTR/L

Provider Business Mailing Address
First Line	:	12938 COLDWATER RD
Second Line	:
City	:	FORT WAYNE
State	:	IN
Zip	:	46845-9517
Country	:	US
Telephone Number	:	260-245-1455
Fax Number	:

Provider Business Practice Location Address
First Line	:	12938 COLDWATER RD
Second Line	:
City	:	FORT WAYNE
State	:	IN
Zip	:	46845-9517
Country	:	US
Telephone Number	:	260-245-1455
Fax Number	:

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

Provider Enumeration Date	:	08/01/2020
Last Update Date	:	08/24/2023

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