MEDICARE: MRS. TERESA BUSAM JONES OTR

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	225XP0200X	Pediatric Occupational Therapist	6583	NC

General Provider Information

NPI Number	:	1720274954
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. TERESA BUSAM JONES OTR

Provider Business Mailing Address
First Line	:	5700 EXECUTIVE CENTER DR
Second Line	:	SUITE 110
City	:	CHARLOTTE
State	:	NC
Zip	:	28212-8858
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	3509 HAWORTH DR
Second Line	:	SUITE 222
City	:	RALEIGH
State	:	NC
Zip	:	27609-7238
Country	:	US
Telephone Number	:	919-662-8340
Fax Number	:	919-832-6405

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

Provider Enumeration Date	:	09/21/2007
Last Update Date	:	09/21/2007

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