Healthcare Provider Details

I. General information

NPI: 1407942022
Provider Name (Legal Business Name): ELIZABETH MARIE GUTBROD OTR L
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/04/2006
Last Update Date: 06/19/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

839 PEARL RD
BRUNSWICK OH
44212-2559
US

IV. Provider business mailing address

5286 MORNING SONG DRIVE
MEDINA OH
44256
US

V. Phone/Fax

Practice location:
  • Phone: 330-225-4182
  • Fax: 330-225-4879
Mailing address:
  • Phone: 330-725-1385
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225XP0200X
TaxonomyPediatric Occupational Therapist
License NumberOT002749
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: