Healthcare Provider Details

I. General information

NPI: 1780170498
Provider Name (Legal Business Name): BACK 2 BASICS OT, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/05/2018
Last Update Date: 09/25/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

134 HONORS WAY
WINTER SPRINGS FL
32708-6352
US

IV. Provider business mailing address

134 HONORS WAY
WINTER SPRINGS FL
32708-6352
US

V. Phone/Fax

Practice location:
  • Phone: 407-376-2592
  • Fax: 407-369-4221
Mailing address:
  • Phone: 407-376-2592
  • Fax: 407-369-4221

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225XP0200X
TaxonomyPediatric Occupational Therapist
License NumberOT14072
License Number StateFL

VIII. Authorized Official

Name: SOLINA BRAININ-MATTOS
Title or Position: OWNER/PRESIDENT
Credential: OTR/L
Phone: 407-376-2592