Healthcare Provider Details

I. General information

NPI: 1952068371
Provider Name (Legal Business Name): ALLISON BAYLEE THIES OT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/19/2021
Last Update Date: 11/19/2021
Certification Date: 11/08/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

400 N. LAKE HOWARD DR
WINTER HAVEN FL
33884
US

IV. Provider business mailing address

1930 AUSTIN TER
WINTER HAVEN FL
33884-2824
US

V. Phone/Fax

Practice location:
  • Phone: 407-530-5063
  • Fax:
Mailing address:
  • Phone: 618-301-8265
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225XP0200X
TaxonomyPediatric Occupational Therapist
License Number462880
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: