Provider Demographics
NPI:1043769458
Name:SLADE, KARLY MITCHELL (COTA/L)
Entity Type:Individual
Prefix:MRS
First Name:KARLY
Middle Name:MITCHELL
Last Name:SLADE
Suffix:
Gender:F
Credentials:COTA/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:75 DUPONT HARTS CHAPEL RD
Mailing Address - Street 2:
Mailing Address - City:POPLARVILLE
Mailing Address - State:MS
Mailing Address - Zip Code:39470-4014
Mailing Address - Country:US
Mailing Address - Phone:601-463-0993
Mailing Address - Fax:
Practice Address - Street 1:311 N MAIN ST
Practice Address - Street 2:
Practice Address - City:PICAYUNE
Practice Address - State:MS
Practice Address - Zip Code:39466-3313
Practice Address - Country:US
Practice Address - Phone:601-799-4065
Practice Address - Fax:601-620-4117
Is Sole Proprietor?:No
Enumeration Date:2016-09-26
Last Update Date:2016-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSTA3243224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant