Healthcare Provider Details

I. General information

NPI: 1144667494
Provider Name (Legal Business Name): DESIREE GAGNE OTR
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/28/2013
Last Update Date: 07/12/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11216 SPRING HILL DR
SPRING HILL FL
34609
US

IV. Provider business mailing address

11216 SPRING HILL DR
SPRING HILL FL
34609
US

V. Phone/Fax

Practice location:
  • Phone: 352-701-0494
  • Fax:
Mailing address:
  • Phone: 352-701-0494
  • Fax: 352-701-0493

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License NumberOT11205
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: