Healthcare Provider Details

I. General information

NPI: 1679035935
Provider Name (Legal Business Name): LISA OBRIEN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/04/2019
Last Update Date: 04/04/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

900 LPGA BLVD
DAYTONA BEACH FL
32117-3113
US

IV. Provider business mailing address

8477 S SUNCOAST BLVD
HOMOSASSA FL
34446-5028
US

V. Phone/Fax

Practice location:
  • Phone: 386-226-9000
  • Fax:
Mailing address:
  • Phone: 352-382-1141
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code224Z00000X
TaxonomyOccupational Therapy Assistant
License NumberOTA12492
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: