=====================================================
General NPI Number Information
=====================================================
NPI Number | 1790728343
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MARY C KEITH OTR
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/13/2006
-----------------------------------------------------
Last Update Date | 01/15/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5333 SW 75TH ST APT D32
-----------------------------------------------------
City | GAINESVILLE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32608-7449
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 850-319-6043
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5333 SW 75TH ST APT D32
-----------------------------------------------------
City | GAINESVILLE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32608-7449
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 850-319-6043
-----------------------------------------------------
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 | 99496
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------