Provider Demographics
NPI:1497391106
Name:SANDERS, TAKISHA KAYON (OTR/L)
Entity Type:Individual
Prefix:
First Name:TAKISHA
Middle Name:KAYON
Last Name:SANDERS
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:TAKISHA
Other - Middle Name:
Other - Last Name:STALLINGS-RICHARDS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OT
Mailing Address - Street 1:4744 WE ROSS PKWY APT 50-201
Mailing Address - Street 2:
Mailing Address - City:SOUTHAVEN
Mailing Address - State:MS
Mailing Address - Zip Code:38671-7003
Mailing Address - Country:US
Mailing Address - Phone:912-308-8143
Mailing Address - Fax:
Practice Address - Street 1:5130 WEDGEWOOD DR
Practice Address - Street 2:
Practice Address - City:OLIVE BRANCH
Practice Address - State:MS
Practice Address - Zip Code:38654-6616
Practice Address - Country:US
Practice Address - Phone:912-308-8143
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-11-18
Last Update Date:2022-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSOT3722225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist