Healthcare Provider Details

I. General information

NPI: 1407612393
Provider Name (Legal Business Name): EVANGELINE ABRAHAM
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/27/2024
Last Update Date: 09/04/2026
Certification Date: 09/04/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4410 S FLORIDA CT
LAKELAND FL
33813-1712
US

IV. Provider business mailing address

4410 S FLORIDA CT
LAKELAND FL
33813-1712
US

V. Phone/Fax

Practice location:
  • Phone: 207-329-5420
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225XP0200X
TaxonomyPediatric Occupational Therapist
License Number21064
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: