MEDICARE: MRS. CONSTANCE ELAM 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	225XP0200X	Pediatric Occupational Therapist	5594	TN
2	225X00000X	Occupational Therapist	OT2571	MS

General Provider Information

NPI Number	:	1912346313
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. CONSTANCE ELAM OT

Provider Business Mailing Address
First Line	:	8767 OVERCUP OAKS DR
Second Line	:
City	:	CORDOVA
State	:	TN
Zip	:	38018-0427
Country	:	US
Telephone Number	:	662-897-3059
Fax Number	:

Provider Business Practice Location Address
First Line	:	3180 PROFESSIONAL PLZ STE 101
Second Line	:
City	:	GERMANTOWN
State	:	TN
Zip	:	38138-1534
Country	:	US
Telephone Number	:	901-328-2104
Fax Number	:

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

Provider Enumeration Date	:	06/19/2013
Last Update Date	:	12/27/2022

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