Provider Demographics
NPI:1043991896
Name:TAMOR, AUTUMN B (OTD, OTR/L)
Entity Type:Individual
Prefix:
First Name:AUTUMN
Middle Name:B
Last Name:TAMOR
Suffix:
Gender:F
Credentials:OTD, OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:908 FAIRVIEW ST
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39202-1114
Mailing Address - Country:US
Mailing Address - Phone:601-551-5612
Mailing Address - Fax:
Practice Address - Street 1:1417 LELIA DR
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39216-4721
Practice Address - Country:US
Practice Address - Phone:601-551-5612
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-07-25
Last Update Date:2024-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSOT-4071225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGroup - Multi-Specialty