Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 224Z00000X | Occupational Therapy Assistant | 518 | OK |
NPI | 1023510385 |
---|---|
Provider Name | Tessa Ellyson |
First Address | Shawnee, OK 74801-3701 |
Second Address | Shawnee, OK 74801-3701 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 02/03/2018 |
Last Update Date | 02/03/2018 |