1093054330 NPI number — MRS. TIERRA S MOMPLAISIR OTR

Table of content: MRS. TIERRA S MOMPLAISIR OTR (NPI 1093054330)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1093054330 NPI number — MRS. TIERRA S MOMPLAISIR OTR

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MOMPLAISIR
Provider First Name:
TIERRA
Provider Middle Name:
S
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
OTR
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
ROBINSON
Provider Other First Name:
TIERRA
Provider Other Middle Name:
Provider Other Name Prefix Text:
MS.
Provider Other Name Suffix Text:
Provider Other Credential Text:
OTR
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1093054330
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/31/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
206 RIDGEWOOD AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BRANDON
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33510-4617
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
863-802-3800
Provider Business Mailing Address Fax Number:
863-802-0480

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
206 RIDGEWOOD AVE PEDIATRIC THERAPY SERVICES
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BRANDON
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
33510-4617
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
813-662-1060
Provider Business Practice Location Address Fax Number:
813-662-0530
Provider Enumeration Date:
02/06/2013

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 225XP0200X , with the licence number:  OT15602 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 225XP0200X , with the licence number: OTT15602 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 008332400 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".
  • Identifier: OTT15602 . This is a "FLORIDA OT LICENSE" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 008332400 . This is a "Florida Medicaid Provider ID" identifier , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




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