Healthcare Provider Details

I. General information

NPI: 1053534818
Provider Name (Legal Business Name): RHONDA JOANN LEE OT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/10/2007
Last Update Date: 02/14/2022
Certification Date: 02/14/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

54 GOLFVIEW TER
ANGEL FIRE NM
87710-8187
US

IV. Provider business mailing address

PO BOX 1213
ANGEL FIRE NM
87710-1213
US

V. Phone/Fax

Practice location:
  • Phone: 575-603-7185
  • Fax:
Mailing address:
  • Phone: 505-603-7185
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number678
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: