Provider Demographics
NPI:1033504816
Name:GILMORE, NIESHA LASHA (OTR/L)
Entity Type:Individual
Prefix:
First Name:NIESHA
Middle Name:LASHA
Last Name:GILMORE
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:519 SCOTT ST
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39203-1825
Mailing Address - Country:US
Mailing Address - Phone:601-951-7458
Mailing Address - Fax:
Practice Address - Street 1:519 SCOTT ST
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39203-1825
Practice Address - Country:US
Practice Address - Phone:601-951-7458
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-03-30
Last Update Date:2015-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSOT2934225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist