=====================================================
General NPI Number Information
=====================================================
NPI Number | 1104355528
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | KIRSTIN DOUGLAS OTR/L
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/08/2017
-----------------------------------------------------
Last Update Date | 07/21/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 455 WEST WARREN AVE 200
-----------------------------------------------------
City | LONGWOOD
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32750-4038
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 407-260-0551
-----------------------------------------------------
Fax | 407-265-9590
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 455 W WARREN AVE STE 200
-----------------------------------------------------
City | LONGWOOD
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32750-4038
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 407-260-0551
-----------------------------------------------------
Fax | 407-265-9590
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225X00000X
-----------------------------------------------------
Taxonomy Name | Occupational Therapist
-----------------------------------------------------
License Number | OT18513
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------