Healthcare Provider Details

I. General information

NPI: 1588080949
Provider Name (Legal Business Name): KHUSHALI NITIN SHAH M.OT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/10/2014
Last Update Date: 03/10/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4907 NW 43RD ST STE C
GAINESVILLE FL
32606-2007
US

IV. Provider business mailing address

5350 E SILVER SPRINGS BLVD
SILVER SPRINGS FL
34488-1714
US

V. Phone/Fax

Practice location:
  • Phone: 352-372-0047
  • Fax:
Mailing address:
  • Phone: 772-812-4339
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225XP0200X
TaxonomyPediatric Occupational Therapist
License Number16240
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: