Healthcare Provider Details

I. General information

NPI: 1740612480
Provider Name (Legal Business Name): LILY YARBROUGH CONDY OTR/L
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/05/2013
Last Update Date: 09/02/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1325 SAN MARCO BLVD SUITE 102
JACKSONVILLE FL
32207-8568
US

IV. Provider business mailing address

1325 SAN MARCO BLVD SUITE 200
JACKSONVILLE FL
32207-8568
US

V. Phone/Fax

Practice location:
  • Phone: 904-858-7045
  • Fax: 904-858-7047
Mailing address:
  • Phone: 904-346-3465
  • Fax: 904-858-7047

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225XG0600X
TaxonomyGerontology Occupational Therapist
License NumberOT005648
License Number StateGA
# 2
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License NumberOT15704
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: