=====================================================
General NPI Number Information
=====================================================
NPI Number | 1174066088
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | LEG UP THERAPY, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/25/2016
-----------------------------------------------------
Last Update Date | 11/25/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5180 NW 75TH AVE
-----------------------------------------------------
City | OCALA
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 34482-6765
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 314-378-7616
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5180 NW 75TH AVE
-----------------------------------------------------
City | OCALA
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 34482-6765
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 314-378-7616
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER/ OCCUPATIONAL THERAPIST
-----------------------------------------------------
Name | CATHERINE LIEBE
-----------------------------------------------------
Credential | MSOTR/L
-----------------------------------------------------
Telephone | 314-378-7616
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225X00000X
-----------------------------------------------------
Taxonomy Name | Occupational Therapist
-----------------------------------------------------
License Number | OT14953
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------