Healthcare Provider Details

I. General information

NPI: 1124816004
Provider Name (Legal Business Name): AALWM CLINIC PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/29/2025
Last Update Date: 09/25/2025
Certification Date: 09/25/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1180 SPRING CENTRE SOUTH BLVD STE 355
ALTAMONTE SPRINGS FL
32714-1999
US

IV. Provider business mailing address

1180 SPRING CENTRE SOUTH BLVD STE 355
ALTAMONTE SPRINGS FL
32714-1999
US

V. Phone/Fax

Practice location:
  • Phone: 407-312-4613
  • Fax: 800-414-3101
Mailing address:
  • Phone: 407-312-4613
  • Fax: 800-414-3101

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code261QR0400X
TaxonomyRehabilitation Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: PHYLEISCHA MAYNE-OWEN
Title or Position: OFFICE MANAGER
Credential:
Phone: 407-312-4613