Healthcare Provider Details

I. General information

NPI: 1285347955
Provider Name (Legal Business Name): CAROL LEWIS WISE OTR/L
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/27/2022
Last Update Date: 12/27/2022
Certification Date: 12/27/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1463 OAKFIELD DR STE 102
BRANDON FL
33511-3893
US

IV. Provider business mailing address

4577 COUNTRY MANOR DR
SARASOTA FL
34233-1869
US

V. Phone/Fax

Practice location:
  • Phone: 813-655-4166
  • Fax:
Mailing address:
  • Phone: 781-424-0161
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225XP0200X
TaxonomyPediatric Occupational Therapist
License Number19406
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: