Provider Demographics
NPI:1831428218
Name:FELICITAS, MARRIETA
Entity type:Individual
Prefix:
First Name:MARRIETA
Middle Name:
Last Name:FELICITAS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:111 CHASE ST
Mailing Address - Street 2:
Mailing Address - City:BYHALIA
Mailing Address - State:MS
Mailing Address - Zip Code:38611-7395
Mailing Address - Country:US
Mailing Address - Phone:662-838-3670
Mailing Address - Fax:662-838-3740
Practice Address - Street 1:111 CHASE ST
Practice Address - Street 2:
Practice Address - City:BYHALIA
Practice Address - State:MS
Practice Address - Zip Code:38611-7395
Practice Address - Country:US
Practice Address - Phone:662-838-3670
Practice Address - Fax:662-838-3740
Is Sole Proprietor?:Yes
Enumeration Date:2009-12-15
Last Update Date:2009-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSOT2187225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist