=====================================================
General NPI Number Information
=====================================================
NPI Number | 1710271374
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | TRIPLE E OT INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/01/2011
-----------------------------------------------------
Last Update Date | 06/01/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4100 S FERDON BLVD SUITE C1
-----------------------------------------------------
City | CRESTVIEW
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32536-5252
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 850-682-8388
-----------------------------------------------------
Fax | 850-682-7463
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 450 LAKEVIEW DR
-----------------------------------------------------
City | DEFUNIAK SPRINGS
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32433-4058
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 850-401-1227
-----------------------------------------------------
Fax | 850-682-7463
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OCCUPATIONAL THERAPIST
-----------------------------------------------------
Name | MRS. KIM EVELYN HYDLE
-----------------------------------------------------
Credential | OTR/L
-----------------------------------------------------
Telephone | 850-401-1227
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225XP0200X
-----------------------------------------------------
Taxonomy Name | Pediatric Occupational Therapist
-----------------------------------------------------
License Number | OT5156
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------