MEDICARE: RONISHA HAWTHORNE OTA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225XG0600X	Gerontology Occupational Therapist	OTA14074	FL

General Provider Information

NPI Number	:	1528748399
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	RONISHA HAWTHORNE OTA

Provider Business Mailing Address
First Line	:	272 LOQUAT RD NW
Second Line	:
City	:	LAKE PLACID
State	:	FL
Zip	:	33852-6541
Country	:	US
Telephone Number	:	863-243-0965
Fax Number	:

Provider Business Practice Location Address
First Line	:	272 LOQUAT RD NW
Second Line	:
City	:	LAKE PLACID
State	:	FL
Zip	:	33852-6541
Country	:	US
Telephone Number	:	863-243-0965
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/18/2023
Last Update Date	:	07/18/2023

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