MEDICARE: MRS. JUANITA DAVIS 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	OT.003133	OH
2	225XG0600X	Gerontology Occupational Therapist	OT.003133	OH
3	225XP0200X	Pediatric Occupational Therapist	OT.003133	OH

General Provider Information

NPI Number	:	1629480827
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. JUANITA DAVIS OTR/L

Provider Business Mailing Address
First Line	:	416 COVE BEACH AVE
Second Line	:
City	:	SHEFFIELD LAKE
State	:	OH
Zip	:	44054-1819
Country	:	US
Telephone Number	:	440-670-7342
Fax Number	:

Provider Business Practice Location Address
First Line	:	416 COVE BEACH AVE
Second Line	:
City	:	SHEFFIELD LAKE
State	:	OH
Zip	:	44054-1819
Country	:	US
Telephone Number	:	440-670-7342
Fax Number	:

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

Provider Enumeration Date	:	05/22/2014
Last Update Date	:	09/30/2014

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