Healthcare Provider Details

I. General information

NPI: 1639801897
Provider Name (Legal Business Name): MIRACIA REGISME OTD, OTR/L
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/27/2022
Last Update Date: 06/27/2022
Certification Date: 06/27/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

627 8TH ST
CLERMONT FL
34711-2159
US

IV. Provider business mailing address

802 KAMCHATKA CT
APOPKA FL
32712-4749
US

V. Phone/Fax

Practice location:
  • Phone: 352-243-4422
  • Fax:
Mailing address:
  • Phone: 561-275-3954
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number23202
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: