Basic Information
| Provider Information | |||||||||
| NPI: | 1386375400 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BAILEY | ||||||||
| FirstName: | CARSON | ||||||||
| MiddleName: | ELISE | ||||||||
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| Credential: | COTA/L | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | HATCH | ||||||||
| OtherFirstName: | CARSON | ||||||||
| OtherMiddleName: | ELISE | ||||||||
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| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 224 HIGH ST | ||||||||
| Address2: | |||||||||
| City: | HUNTINGDON | ||||||||
| State: | TN | ||||||||
| PostalCode: | 383443206 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7314990295 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 14510 HIGHWAY 79 | ||||||||
| Address2: | |||||||||
| City: | MC KENZIE | ||||||||
| State: | TN | ||||||||
| PostalCode: | 382017824 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7313525317 | ||||||||
| FaxNumber: | 7313525942 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/20/2022 | ||||||||
| LastUpdateDate: | 06/20/2022 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 06/20/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 224Z00000X | 3826 | TN | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapy Assistant |
No ID Information.