=====================================================
General NPI Number Information
=====================================================
NPI Number | 1669794244
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | TERESA HUMBERT DOCTOR OF OT
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/23/2010
-----------------------------------------------------
Last Update Date | 02/23/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 400 INTERNATIONAL PKWY SUITE 300
-----------------------------------------------------
City | LAKE MARY
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32746-5061
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 407-833-8815
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 121 9TH ST W
-----------------------------------------------------
City | HASTINGS
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55033-2020
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 651-249-1983
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225X00000X
-----------------------------------------------------
Taxonomy Name | Occupational Therapist
-----------------------------------------------------
License Number | 4854026
-----------------------------------------------------
License Number State | WI
-----------------------------------------------------