Healthcare Provider Details

I. General information

NPI: 1659406122
Provider Name (Legal Business Name): MANDY M REPICE OTRIL
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/23/2007
Last Update Date: 11/10/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1715 HERITAGE TRL
NAPLES FL
34112-8715
US

IV. Provider business mailing address

7071 SUGAR MAGNOLIA CIR
NAPLES FL
34109-7833
US

V. Phone/Fax

Practice location:
  • Phone: 239-530-3040
  • Fax:
Mailing address:
  • Phone: 239-598-3356
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License NumberOT12089
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: