Healthcare Provider Details

I. General information

NPI: 1811249493
Provider Name (Legal Business Name): KATHERINE ROSALIE SHETLER OTR/L
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/08/2012
Last Update Date: 10/08/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

190 SOUTHPARK BLVD # 100
ST AUGUSTINE FL
32086-4120
US

IV. Provider business mailing address

3599 UNIVERSITY BLVD S
JACKSONVILLE FL
32216-4252
US

V. Phone/Fax

Practice location:
  • Phone: 904-824-1478
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License NumberOT13085
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: