Healthcare Provider Details

I. General information

NPI: 1457435455
Provider Name (Legal Business Name): EDITH SELDEN EZELL OTR/L
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/25/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4 JACKSON ST NE
FORT WALTON BEACH FL
32548-4925
US

IV. Provider business mailing address

501 BLACKWATER RUN
NICEVILLE FL
32578-1642
US

V. Phone/Fax

Practice location:
  • Phone: 850-862-7227
  • Fax:
Mailing address:
  • Phone: 850-678-6400
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number9614
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: