Healthcare Provider Details

I. General information

NPI: 1598831711
Provider Name (Legal Business Name): LISA ANN BRANSCUM OTR
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: LISA ANN WICKS OTR

II. Dates (important events)

Enumeration Date: 11/28/2006
Last Update Date: 12/03/2025
Certification Date: 12/03/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1499 6TH ST NW
WINTER HAVEN FL
33881-2365
US

IV. Provider business mailing address

1499 6TH ST NW
WINTER HAVEN FL
33881-2365
US

V. Phone/Fax

Practice location:
  • Phone: 863-293-7778
  • Fax: 863-299-3836
Mailing address:
  • Phone: 863-293-7778
  • Fax: 863-299-3836

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number31002976A
License Number StateIN
# 2
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License NumberOT26593
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: