=====================================================
General NPI Number Information
=====================================================
NPI Number | 1548889678
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MOMENTUM OCCUPATIONAL THERAPY LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/09/2020
-----------------------------------------------------
Last Update Date | 04/09/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 661 NE 4TH PL
-----------------------------------------------------
City | HIALEAH
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33010-5010
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 786-436-0693
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 661 NE 4TH PL
-----------------------------------------------------
City | HIALEAH
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33010-5010
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 786-436-0693
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO
-----------------------------------------------------
Name | ASHLEY MELISSA CASTILLO
-----------------------------------------------------
Credential | MS, OTR/L
-----------------------------------------------------
Telephone | 786-436-0693
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225X00000X
-----------------------------------------------------
Taxonomy Name | Occupational Therapist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------