MEDICARE: KELLY TOLER OT

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	OT1535	MS

General Provider Information

NPI Number	:	1225274962
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KELLY TOLER OT

Provider Business Mailing Address
First Line	:	PO BOX 720610
Second Line	:
City	:	BYRAM
State	:	MS
Zip	:	39272-0610
Country	:	US
Telephone Number	:	601-346-9191
Fax Number	:	601-346-5011

Provider Business Practice Location Address
First Line	:	7213 S SIWELL RD
Second Line	:
City	:	BYRAM
State	:	MS
Zip	:	39272-9776
Country	:	US
Telephone Number	:	601-346-9191
Fax Number	:	601-346-5011

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

Provider Enumeration Date	:	12/31/2008
Last Update Date	:	12/31/2008

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Directions to “ KELLY TOLER OT” Practice Location

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