Healthcare Provider Details

I. General information

NPI: 1003316274
Provider Name (Legal Business Name): TYLER SCOTT LACERTOSA OTD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/14/2018
Last Update Date: 02/14/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

201 N CLYDE MORRIS BLVD STE 300
DAYTONA BEACH FL
32114-2765
US

IV. Provider business mailing address

3901 UNIVERSITY BLVD S
JACKSONVILLE FL
32216-4312
US

V. Phone/Fax

Practice location:
  • Phone: 386-236-7017
  • Fax:
Mailing address:
  • Phone: 904-345-7336
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number18954
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: