Healthcare Provider Details

I. General information

NPI: 1710271374
Provider Name (Legal Business Name): TRIPLE E OT INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/01/2011
Last Update Date: 06/01/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4100 S FERDON BLVD SUITE C1
CRESTVIEW FL
32536-5252
US

IV. Provider business mailing address

450 LAKEVIEW DR
DEFUNIAK SPRINGS FL
32433-4058
US

V. Phone/Fax

Practice location:
  • Phone: 850-682-8388
  • Fax: 850-682-7463
Mailing address:
  • Phone: 850-401-1227
  • Fax: 850-682-7463

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225XP0200X
TaxonomyPediatric Occupational Therapist
License NumberOT5156
License Number StateFL

VIII. Authorized Official

Name: MRS. KIM EVELYN HYDLE
Title or Position: OCCUPATIONAL THERAPIST
Credential: OTR/L
Phone: 850-401-1227