Basic Information
| Provider Information | |||||||||
| NPI: | 1700923307 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | POWELL | ||||||||
| FirstName: | MARY | ||||||||
| MiddleName: | CAMILLE | ||||||||
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| Credential: | OT/L | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2319 HWY 145 | ||||||||
| Address2: | |||||||||
| City: | SALTILLO | ||||||||
| State: | MS | ||||||||
| PostalCode: | 38866 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6628699970 | ||||||||
| FaxNumber: | 6628699980 | ||||||||
| Practice Location | |||||||||
| Address1: | 2319 HIGHWAY 145 | ||||||||
| Address2: | |||||||||
| City: | SALTILLO | ||||||||
| State: | MS | ||||||||
| PostalCode: | 388669199 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6628699970 | ||||||||
| FaxNumber: | 6628699980 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/31/2007 | ||||||||
| LastUpdateDate: | 09/01/2015 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225X00000X | OT0669 | MS | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist |
ID Information
| ID | Type | State | Issuer | Description | 07857321 | 05 | MS | MEDICAID |