Healthcare Provider Details

I. General information

NPI: 1639266091
Provider Name (Legal Business Name): RENEE D PHARES OTR
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/06/2006
Last Update Date: 07/09/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

405 S SEMINOLE AVE
MINNEOLA FL
34715-5520
US

IV. Provider business mailing address

17355 CORK ST
WINTER GARDEN FL
34787-9700
US

V. Phone/Fax

Practice location:
  • Phone: 352-394-0212
  • Fax: 352-241-6361
Mailing address:
  • Phone: 407-654-7624
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225XP0200X
TaxonomyPediatric Occupational Therapist
License NumberOT1509
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: