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General NPI Number Information
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NPI Number | 1104706837
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Entity Type | Organization
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Legal Business Name | MOBILE LYMPHEDEMA CLINIC, LLC
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Dates
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Enumeration Date | 09/04/2025
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Last Update Date | 11/25/2025
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Provider Practice Location Address
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Address Line | 804 PINE ALLEY ST
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City | FORT WALTON BEACH
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State | FL
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Zip | 32547-1216
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Country | US
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Telephone | 850-803-6683
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Fax |
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Provider Business Mailing Address
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Address Line | 804 PINE ALLEY ST
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City | FORT WALTON BEACH
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State | FL
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Zip | 32547-1216
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Country | US
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Telephone | 850-803-6683
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Fax | 888-857-4412
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Authorized Official
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Title or Position | CLINICIAN
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Name | JESSICA COLLEEN BOOTHE
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Credential | MSOT, OTR/L, CLT
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Telephone | 850-803-6683
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 225XG0600X
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Taxonomy Name | Gerontology Occupational Therapist
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 225XE1200X
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Taxonomy Name | Ergonomics Occupational Therapist
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License Number |
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License Number State |
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Taxonomy #3
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Taxonomy Code | 225XP0019X
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Taxonomy Name | Physical Rehabilitation Occupational Therapist
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License Number |
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License Number State |
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Taxonomy #4
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Taxonomy Code | 225XE0001X
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Taxonomy Name | Environmental Modification Occupational Therapist
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License Number |
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License Number State |
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Taxonomy #5
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Taxonomy Code | 225400000X
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Taxonomy Name | Rehabilitation Practitioner
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License Number |
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License Number State |
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Taxonomy #6
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Taxonomy Code | 225XH1200X
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Taxonomy Name | Hand Occupational Therapist
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License Number |
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License Number State |
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Taxonomy #7
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Taxonomy Code | 225X00000X
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Taxonomy Name | Occupational Therapist
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License Number |
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License Number State |
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