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General NPI Number Information
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NPI Number | 1780170498
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Entity Type | Organization
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Legal Business Name | BACK 2 BASICS OT, LLC
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Dates
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Enumeration Date | 07/05/2018
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Last Update Date | 09/25/2018
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Provider Practice Location Address
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Address Line | 134 HONORS WAY
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City | WINTER SPRINGS
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State | FL
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Zip | 32708-6352
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Country | US
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Telephone | 407-376-2592
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Fax | 407-369-4221
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Provider Business Mailing Address
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Address Line | 134 HONORS WAY
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City | WINTER SPRINGS
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State | FL
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Zip | 32708-6352
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Country | US
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Telephone | 407-376-2592
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Fax | 407-369-4221
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Authorized Official
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Title or Position | OWNER/PRESIDENT
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Name | SOLINA BRAININ-MATTOS
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Credential | OTR/L
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Telephone | 407-376-2592
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 225XP0200X
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Taxonomy Name | Pediatric Occupational Therapist
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License Number | OT14072
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License Number State | FL
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