=====================================================
General NPI Number Information
=====================================================
NPI Number | 1366033888
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | LIFE INSPIRED THERAPY, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/27/2021
-----------------------------------------------------
Last Update Date | 01/27/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2229 NATURAL WELLS DR
-----------------------------------------------------
City | TALLAHASSEE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32305-2123
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 850-212-1486
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 7622
-----------------------------------------------------
City | TALLAHASSEE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32314-7622
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 850-212-1486
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO/OWNER
-----------------------------------------------------
Name | LAQWANA SMITH
-----------------------------------------------------
Credential | OTR/L
-----------------------------------------------------
Telephone | 850-212-1486
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225X00000X
-----------------------------------------------------
Taxonomy Name | Occupational Therapist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------