=====================================================
General NPI Number Information
=====================================================
NPI Number | 1497340715
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | BETHANY O MACDONALD LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/08/2021
-----------------------------------------------------
Last Update Date | 03/08/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 21535 SOUTHERN CHARM DR
-----------------------------------------------------
City | LAND O LAKES
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 34637-7629
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 813-375-1591
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 21535 SOUTHERN CHARM DR
-----------------------------------------------------
City | LAND O LAKES
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 34637-7629
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 813-375-1591
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | BETHANY O MACDONALD
-----------------------------------------------------
Credential | OTR/L
-----------------------------------------------------
Telephone | 813-375-1591
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225XP0019X
-----------------------------------------------------
Taxonomy Name | Physical Rehabilitation Occupational Therapist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 225XP0200X
-----------------------------------------------------
Taxonomy Name | Pediatric Occupational Therapist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------