Healthcare Provider Details

I. General information

NPI: 1912492588
Provider Name (Legal Business Name): MINDRA ASHLEY PEREZ
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/26/2018
Last Update Date: 06/26/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

56 POST VIEW DR
PALM COAST FL
32164-4948
US

IV. Provider business mailing address

PO BOX 1088
BUNNELL FL
32110-1088
US

V. Phone/Fax

Practice location:
  • Phone: 386-270-2664
  • Fax:
Mailing address:
  • Phone: 386-270-2664
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code224Z00000X
TaxonomyOccupational Therapy Assistant
License NumberOTA13611
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code224ZF0002X
TaxonomyFeeding, Eating & Swallowing Occupational Therapy Assistant
License NumberOTA13611
License Number StateFL
# 3
Primary TaxonomyN
Taxonomy Code224ZL0004X
TaxonomyLow Vision Occupational Therapy Assistant
License Number
License Number StateNULL
# 4
Primary TaxonomyN
Taxonomy Code224ZE0001X
TaxonomyEnvironmental Modification Occupational Therapy Assistant
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: