MEDICARE: TAKISHA KAYON SANDERS 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	225X00000X	Occupational Therapist	OT3722	MS

General Provider Information

NPI Number	:	1497391106
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	TAKISHA KAYON SANDERS OTR/L

Provider Business Mailing Address
First Line	:	4744 WE ROSS PKWY APT 50-201
Second Line	:
City	:	SOUTHAVEN
State	:	MS
Zip	:	38671-7003
Country	:	US
Telephone Number	:	912-308-8143
Fax Number	:

Provider Business Practice Location Address
First Line	:	5130 WEDGEWOOD DR
Second Line	:
City	:	OLIVE BRANCH
State	:	MS
Zip	:	38654-6616
Country	:	US
Telephone Number	:	912-308-8143
Fax Number	:

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

Provider Enumeration Date	:	11/18/2019
Last Update Date	:	08/09/2022

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