Provider Demographics
NPI:1154383511
Name:MALLETT, MEAGEN M (OT)
Entity type:Individual
Prefix:MRS
First Name:MEAGEN
Middle Name:M
Last Name:MALLETT
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 1:199 BROOKMOORE DRIVE
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:MS
Mailing Address - Zip Code:39705
Mailing Address - Country:US
Mailing Address - Phone:662-327-6705
Mailing Address - Fax:662-327-6760
Practice Address - Street 1:950 E COUNTY LINE RD
Practice Address - Street 2:STE E
Practice Address - City:RIDGELAND
Practice Address - State:MS
Practice Address - Zip Code:39157-1928
Practice Address - Country:US
Practice Address - Phone:601-853-9147
Practice Address - Fax:601-898-4761
Is Sole Proprietor?:No
Enumeration Date:2006-04-03
Last Update Date:2017-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSOT1419225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS07685379Medicaid