Healthcare Provider Details

I. General information

NPI: 1073654539
Provider Name (Legal Business Name): CAROL E TIETZOTR/LPA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/09/2007
Last Update Date: 02/06/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10521 HEARTH RD
SPRING HILL FL
34608-3714
US

IV. Provider business mailing address

6325 MONTANA AVE
NEW PORT RICHEY FL
34653-3833
US

V. Phone/Fax

Practice location:
  • Phone: 727-375-0600
  • Fax: 727-375-1117
Mailing address:
  • Phone: 727-809-3326
  • Fax: 727-845-1811

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225XP0200X
TaxonomyPediatric Occupational Therapist
License NumberOT1010
License Number StateFL

VIII. Authorized Official

Name: CAROL E TIETZ
Title or Position: OWNER
Credential: OTR L
Phone: 727-809-3326