Healthcare Provider Details

I. General information

NPI: 1629404785
Provider Name (Legal Business Name): MARIE OLIVAS-GOMEZ OTR/L
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: MARIE OLIVAS

II. Dates (important events)

Enumeration Date: 09/20/2013
Last Update Date: 01/10/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

427 BURNS AVE
LAKE WALES FL
33853
US

IV. Provider business mailing address

18539 SW 12TH ST
PEMBROKE PINES FL
33029-6017
US

V. Phone/Fax

Practice location:
  • Phone: 863-679-3338
  • Fax:
Mailing address:
  • Phone: 954-696-8023
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License NumberOT18827
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: