Provider Demographics
NPI:1427538305
Name:BAKER, BEVERLY COLE (OTR/L)
Entity type:Individual
Prefix:MRS
First Name:BEVERLY
Middle Name:COLE
Last Name:BAKER
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 1:2304 JACKSON AVE W
Mailing Address - Street 2:
Mailing Address - City:OXFORD
Mailing Address - State:MS
Mailing Address - Zip Code:38655-5416
Mailing Address - Country:US
Mailing Address - Phone:662-234-8559
Mailing Address - Fax:
Practice Address - Street 1:140 BURKE CALHOUN CITY RD
Practice Address - Street 2:
Practice Address - City:CALHOUN CITY
Practice Address - State:MS
Practice Address - Zip Code:38916-9690
Practice Address - Country:US
Practice Address - Phone:662-628-4244
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-08-20
Last Update Date:2018-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSOT3051225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00020213Medicaid