Healthcare Provider Details

I. General information

NPI: 1932741659
Provider Name (Legal Business Name): FUNCTIONALITY FOR LIFE, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/14/2019
Last Update Date: 10/07/2021
Certification Date: 10/01/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1234 KATAHDIN CT
WESLEY CHAPEL FL
33543-6860
US

IV. Provider business mailing address

1234 KATAHDIN CT
WESLEY CHAPEL FL
33543-6860
US

V. Phone/Fax

Practice location:
  • Phone: 813-442-1204
  • Fax:
Mailing address:
  • Phone: 813-442-1204
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225XE0001X
TaxonomyEnvironmental Modification Occupational Therapist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code225XG0600X
TaxonomyGerontology Occupational Therapist
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code225XH1300X
TaxonomyHuman Factors Occupational Therapist
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code225XL0004X
TaxonomyLow Vision Occupational Therapist
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code225XM0800X
TaxonomyMental Health Occupational Therapist
License Number
License Number State
# 6
Primary TaxonomyN
Taxonomy Code225XP0019X
TaxonomyPhysical Rehabilitation Occupational Therapist
License Number
License Number State
# 7
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number State
# 8
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number
License Number State

VIII. Authorized Official

Name: JENNIFER TREVINO
Title or Position: OWNER
Credential: OTR/L
Phone: 813-442-1204