Healthcare Provider Details

I. General information

NPI: 1275332736
Provider Name (Legal Business Name): CAROLINE MCGAVOCK OTR/L
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/10/2025
Last Update Date: 03/10/2025
Certification Date: 03/09/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

124 JOHN KING RD
CRESTVIEW FL
32539-8306
US

IV. Provider business mailing address

286 PINE NEEDLE WAY
SANTA ROSA BEACH FL
32459-7921
US

V. Phone/Fax

Practice location:
  • Phone: 850-634-6020
  • Fax:
Mailing address:
  • Phone: 806-782-2964
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225XP0200X
TaxonomyPediatric Occupational Therapist
License NumberOT25991
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: