Healthcare Provider Details

I. General information

NPI: 1972847424
Provider Name (Legal Business Name): EVELYN MIRANDA LEVASSEUR OTR
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/22/2012
Last Update Date: 11/22/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1240 PINEBROOK RD
VENICE FL
34285-6421
US

IV. Provider business mailing address

22144 MAMARONECK AVE
PORT CHARLOTTE FL
33952-6925
US

V. Phone/Fax

Practice location:
  • Phone: 941-488-6733
  • Fax: 941-484-5610
Mailing address:
  • Phone: 941-488-6733
  • Fax: 941-484-5610

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225XP0019X
TaxonomyPhysical Rehabilitation Occupational Therapist
License NumberOT2027
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: