Healthcare Provider Details

I. General information

NPI: 1780404566
Provider Name (Legal Business Name): TIERRA BELCHER C/OTA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/15/2024
Last Update Date: 10/16/2024
Certification Date: 10/16/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6535 CHESTER AVE
JACKSONVILLE FL
32217-2247
US

IV. Provider business mailing address

6601 CHESTER AVE
JACKSONVILLE FL
32217-2252
US

V. Phone/Fax

Practice location:
  • Phone: 904-731-8230
  • Fax: 904-367-0021
Mailing address:
  • Phone: 904-636-0313
  • Fax: 904-367-0021

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code224Z00000X
TaxonomyOccupational Therapy Assistant
License NumberOAT20068
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: