Provider Demographics
NPI:1053579409
Name:BLACK, KATIE OGLETREE (OT)
Entity type:Individual
Prefix:MRS
First Name:KATIE
Middle Name:OGLETREE
Last Name:BLACK
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 1:1350 E WOODROW WILSON AVE
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39216-5112
Mailing Address - Country:US
Mailing Address - Phone:601-981-2611
Mailing Address - Fax:
Practice Address - Street 1:1350 E WOODROW WILSON AVE
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39216-5112
Practice Address - Country:US
Practice Address - Phone:601-981-2611
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-06-01
Last Update Date:2008-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS1731225XN1300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XN1300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistNeurorehabilitation