=====================================================
General NPI Number Information
=====================================================
NPI Number | 1760809545
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ESTEEM REHABILITATION
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/18/2014
-----------------------------------------------------
Last Update Date | 06/16/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 196 LEE MILLER RD
-----------------------------------------------------
City | CRAWFORDVILLE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32327
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 850-491-7826
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 102 W 5TH AVE STE 1
-----------------------------------------------------
City | TALLAHASSEE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32303-6125
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 850-491-7826
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER/OCCUPATIONAL THERAPIST
-----------------------------------------------------
Name | MRS. AMBER L. WILLIAMS
-----------------------------------------------------
Credential | OT/L
-----------------------------------------------------
Telephone | 850-491-7826
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 305S00000X
-----------------------------------------------------
Taxonomy Name | Point of Service
-----------------------------------------------------
License Number | OT9333
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------