Healthcare Provider Details

I. General information

NPI: 1700072915
Provider Name (Legal Business Name): WENDY LEA HEALY MOTR/L
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: WENDY LEA BROOKS MOTR/L

II. Dates (important events)

Enumeration Date: 09/20/2007
Last Update Date: 09/20/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1689 EAGLE HARBOR PKWY STE D
ORANGE PARK FL
32003-4802
US

IV. Provider business mailing address

1689 EAGLE HARBOR PKWY STE D
ORANGE PARK FL
32003-4802
US

V. Phone/Fax

Practice location:
  • Phone: 904-637-0148
  • Fax:
Mailing address:
  • Phone: 904-637-0148
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License NumberOT 9668
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: