Provider Demographics
NPI:1720566672
Name:LIDDON, EMILY (OTR)
Entity Type:Individual
Prefix:
First Name:EMILY
Middle Name:
Last Name:LIDDON
Suffix:
Gender:F
Credentials:OTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1535 WINCHESTER ST
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39211-5641
Mailing Address - Country:US
Mailing Address - Phone:662-590-5842
Mailing Address - Fax:
Practice Address - Street 1:7712 OLD CANTON RD
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:MS
Practice Address - Zip Code:39110-9299
Practice Address - Country:US
Practice Address - Phone:601-427-5775
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-08-02
Last Update Date:2018-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSOT3496225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
1508125899OtherGROUP FOR A FOCUSED BRAIN, LLC