1164849394 NPI number — INTEGRATION OT IN PEDIATRICS

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1164849394 NPI number — INTEGRATION OT IN PEDIATRICS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
INTEGRATION OT IN PEDIATRICS
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1164849394
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/26/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
701 BRICKELL KEY BLVD
Provider Second Line Business Mailing Address:
1607
Provider Business Mailing Address City Name:
MIAMI
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33131-2674
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
786-510-0814
Provider Business Mailing Address Fax Number:
305-359-9261

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
701 BRICKELL KEY BLVD
Provider Second Line Business Practice Location Address:
1607
Provider Business Practice Location Address City Name:
MIAMI
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
33131-2674
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
786-510-0814
Provider Business Practice Location Address Fax Number:
305-359-9261
Provider Enumeration Date:
03/26/2014

Additional Information

Authorized Official

Authorized Official Last Name:
HORN-MANDIOLA
Authorized Official First Name:
MARCELLE
Authorized Official Middle Name:
Authorized Official Title or Position:
OCCUPATIONAL THERAPIST
Authorized Official Telephone Number:
786-510-0814

Provider Taxonomy Codes

  • Taxonomy code: 225XP0200X , with the licence number:  4403 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 004591600 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




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