Healthcare Provider Details

I. General information

NPI: 1326645128
Provider Name (Legal Business Name): ALYSSA LYNN SIMON OTR/L
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/05/2020
Last Update Date: 10/05/2020
Certification Date: 10/05/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4925 GRANDE DR
PENSACOLA FL
32504-8965
US

IV. Provider business mailing address

1319 CONNEMARA CIR
GULF BREEZE FL
32563-8956
US

V. Phone/Fax

Practice location:
  • Phone: 850-746-4901
  • Fax:
Mailing address:
  • Phone: 404-513-3258
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number20940
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: