Healthcare Provider Details

I. General information

NPI: 1679353528
Provider Name (Legal Business Name): ELISHA CONWAY OTA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: ELISHA SCHMIDT

II. Dates (important events)

Enumeration Date: 09/28/2023
Last Update Date: 09/28/2023
Certification Date: 09/18/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14025 RIVEREDGE DR
TAMPA FL
33637-2089
US

IV. Provider business mailing address

5927 ELM ST
NEW PORT RICHEY FL
34652-4111
US

V. Phone/Fax

Practice location:
  • Phone: 813-558-6500
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code224Z00000X
TaxonomyOccupational Therapy Assistant
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: