Healthcare Provider Details

I. General information

NPI: 1710184650
Provider Name (Legal Business Name): MARY LOU DAVIS IX OT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/02/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2679 N FOREST RIDGE BLVD
HERNANDO FL
34442-5123
US

IV. Provider business mailing address

2679 N FOREST RIDGE BLVD
HERNANDO FL
34442-5123
US

V. Phone/Fax

Practice location:
  • Phone: 352-746-2371
  • Fax: 352-746-3729
Mailing address:
  • Phone: 352-746-2371
  • Fax: 352-746-3729

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License NumberOT10044
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: