Healthcare Provider Details

I. General information

NPI: 1407290059
Provider Name (Legal Business Name): VIRGINIA LEESON MSOTR/L, CLT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/25/2013
Last Update Date: 05/06/2024
Certification Date: 05/06/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

479 NW PRIMA VISTA BLVD
PORT ST LUCIE FL
34983-8731
US

IV. Provider business mailing address

479 NW PRIMA VISTA BLVD
PORT ST LUCIE FL
34983-8731
US

V. Phone/Fax

Practice location:
  • Phone: 772-408-4848
  • Fax: 772-408-0978
Mailing address:
  • Phone: 772-408-4848
  • Fax: 772-408-0978

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License NumberOT23103
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: