Healthcare Provider Details

I. General information

NPI: 1700121209
Provider Name (Legal Business Name): DANIELLE RONQUILLE LIPSKI MOT, OTR/L, CLT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/10/2012
Last Update Date: 10/23/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1340 BROAD AVE SUITE 270
GULFPORT MS
39501-2404
US

IV. Provider business mailing address

1340 BROAD AVE STE 160
GULFPORT MS
39501-2445
US

V. Phone/Fax

Practice location:
  • Phone: 228-575-1234
  • Fax: 228-575-1240
Mailing address:
  • Phone: 228-575-2906
  • Fax: 228-865-3058

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License NumberOT1900
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: