Healthcare Provider Details

I. General information

NPI: 1457622243
Provider Name (Legal Business Name): ROBERT THEODORE MENTZ III OTR/L
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/25/2012
Last Update Date: 11/25/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3159 JULINGTON CREEK RD
JACKSONVILLE FL
32223-2727
US

IV. Provider business mailing address

3159 JULINGTON CREEK RD
JACKSONVILLE FL
32223
US

V. Phone/Fax

Practice location:
  • Phone: 904-651-1498
  • Fax:
Mailing address:
  • Phone: 904-651-1498
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License NumberOT8409
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code225XG0600X
TaxonomyGerontology Occupational Therapist
License NumberOT8409
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: