MEDICARE: MRS. DEBRA EAINE PUCKETT OTL

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	2140	AL

General Provider Information

NPI Number	:	1255454849
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. DEBRA EAINE PUCKETT OTL

Provider Business Mailing Address
First Line	:	1597 MCCURDY AVE N
Second Line	:
City	:	RAINSVILLE
State	:	AL
Zip	:	35986-4429
Country	:	US
Telephone Number	:	256-638-9350
Fax Number	:

Provider Business Practice Location Address
First Line	:	112 68TH ST NW
Second Line	:
City	:	FORT PAYNE
State	:	AL
Zip	:	35967-8300
Country	:	US
Telephone Number	:	256-997-9929
Fax Number	:	256-844-2994

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

Provider Enumeration Date	:	04/09/2007
Last Update Date	:	07/08/2007

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