Provider Demographics
NPI:1497715148
Name:MMBO-KEITH, MAUD N (OTR/L)
Entity Type:Individual
Prefix:MS
First Name:MAUD
Middle Name:N
Last Name:MMBO-KEITH
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 1:405 WAKE ROBIN CT
Mailing Address - Street 2:
Mailing Address - City:FLORENCE
Mailing Address - State:SC
Mailing Address - Zip Code:29505-3189
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:148 SAULS ST
Practice Address - Street 2:STE B
Practice Address - City:LAKE CITY
Practice Address - State:SC
Practice Address - Zip Code:29560-2631
Practice Address - Country:US
Practice Address - Phone:843-374-0185
Practice Address - Fax:843-374-0189
Is Sole Proprietor?:No
Enumeration Date:2006-03-26
Last Update Date:2017-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC1487225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC7301897Medicaid
SCQ340088364Medicare ID - Type UnspecifiedOCCUPATIONAL THERAPIST
SCTH1051Medicaid