MEDICARE: MARY LOU DAVIS IX 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	OT10044	FL

General Provider Information

NPI Number	:	1710184650
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MARY LOU DAVIS IX OT

Provider Business Mailing Address
First Line	:	2679 N FOREST RIDGE BLVD
Second Line	:
City	:	HERNANDO
State	:	FL
Zip	:	34442-5123
Country	:	US
Telephone Number	:	352-746-2371
Fax Number	:	352-746-3729

Provider Business Practice Location Address
First Line	:	2679 N FOREST RIDGE BLVD
Second Line	:
City	:	HERNANDO
State	:	FL
Zip	:	34442-5123
Country	:	US
Telephone Number	:	352-746-2371
Fax Number	:	352-746-3729

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

Provider Enumeration Date	:	07/02/2007
Last Update Date	:	07/08/2007

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