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General NPI Number Information
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NPI Number | 1255825055
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Entity Type | Organization
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Legal Business Name | LIFE ENRICHMENT & WELLNESS
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Dates
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Enumeration Date | 06/15/2018
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Last Update Date | 08/09/2018
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Provider Practice Location Address
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Address Line | 552 10TH PL
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City | VERO BEACH
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State | FL
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Zip | 32960
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Country | US
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Telephone | 772-494-3010
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Fax |
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Provider Business Mailing Address
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Address Line | 552 10TH PL
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City | VERO BEACH
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State | FL
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Zip | 32960-6823
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Country | US
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Telephone | 772-494-3010
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Fax |
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Authorized Official
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Title or Position | OCCUPATIONAL THERAPIST
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Name | CAROL ANN DEFAZIO
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Credential | MSOTR
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Telephone | 772-494-3010
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 225X00000X
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Taxonomy Name | Occupational Therapist
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License Number | OT13709
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License Number State | FL
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