Provider Demographics
NPI:1568758480
Name:POUGH, TAMEKIA (OT)
Entity Type:Individual
Prefix:MRS
First Name:TAMEKIA
Middle Name:
Last Name:POUGH
Suffix:
Gender:F
Credentials:OT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:23804 EAGLE PASS RD
Mailing Address - Street 2:APT 2
Mailing Address - City:FORT RILEY
Mailing Address - State:KS
Mailing Address - Zip Code:66442-2669
Mailing Address - Country:US
Mailing Address - Phone:601-543-5370
Mailing Address - Fax:
Practice Address - Street 1:23804 EAGLE PASS RD
Practice Address - Street 2:APT 2
Practice Address - City:FORT RILEY
Practice Address - State:KS
Practice Address - Zip Code:66442-2669
Practice Address - Country:US
Practice Address - Phone:601-543-5370
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-06-20
Last Update Date:2015-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KST-04056225X00000X
MSTA1999224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant
No225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist