MEDICARE: BAILY CROLLEY CRISMAN OTD

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

General Provider Information

NPI Number	:	1205629789
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	BAILY CROLLEY CRISMAN OTD

Provider Business Mailing Address
First Line	:	134 DIAL LN
Second Line	:
City	:	MONCKS CORNER
State	:	SC
Zip	:	29461-5930
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1411 OLIVER RD STE 200
Second Line	:
City	:	FAIRFIELD
State	:	CA
Zip	:	94534-3429
Country	:	US
Telephone Number	:	707-428-1311
Fax Number	:

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

Provider Enumeration Date	:	05/27/2025
Last Update Date	:	05/27/2025

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