Healthcare Provider Details

I. General information

NPI: 1952138042
Provider Name (Legal Business Name): BELFAZAR GRANT OTR/L
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/13/2024
Last Update Date: 09/13/2024
Certification Date: 09/13/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

801 OAK ST
GREEN COVE SPRINGS FL
32043-4317
US

IV. Provider business mailing address

1386 FALCONWOOD CT
APOPKA FL
32712-2346
US

V. Phone/Fax

Practice location:
  • Phone: 904-284-9230
  • Fax:
Mailing address:
  • Phone: 407-227-4708
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License NumberOT17108
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: