Healthcare Provider Details

I. General information

NPI: 1518265453
Provider Name (Legal Business Name): LAEL PASCHAL KALTZ
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/02/2011
Last Update Date: 10/10/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1673 HASTINGS HAMMOCK LN
FLEMING ISLAND FL
32003-7211
US

IV. Provider business mailing address

1673 HASTINGS HAMMOCK LN
FLEMING ISLAND FL
32003-7211
US

V. Phone/Fax

Practice location:
  • Phone: 904-505-3639
  • Fax:
Mailing address:
  • Phone: 904-505-3639
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License NumberOT13977
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: