MEDICARE: MRS. MARY STACY LILES OTRL

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	225X00000X	Occupational Therapist	OT 9254	FL

General Provider Information

NPI Number	:	1912123399
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. MARY STACY LILES OTRL

Provider Business Mailing Address
First Line	:	4833 STAGHORN CT
Second Line	:
City	:	WINTER SPRINGS
State	:	FL
Zip	:	32708-4926
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	4833 STAGHORN CT
Second Line	:
City	:	WINTER SPRINGS
State	:	FL
Zip	:	32708-4926
Country	:	US
Telephone Number	:	407-760-7030
Fax Number	:	321-972-5028

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

Provider Enumeration Date	:	04/17/2007
Last Update Date	:	06/01/2009

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