=====================================================
General NPI Number Information
=====================================================
NPI Number | 1922370261
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PROVISION REHAB INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/02/2012
-----------------------------------------------------
Last Update Date | 02/29/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3610 OLD LIGHTHOUSE CIR
-----------------------------------------------------
City | WELLINGTON
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33414-8843
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 561-352-4939
-----------------------------------------------------
Fax | 561-333-0994
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3610 OLD LIGHTHOUSE CIR
-----------------------------------------------------
City | WELLINGTON
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33414-8843
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 561-352-4939
-----------------------------------------------------
Fax | 561-333-0994
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRES
-----------------------------------------------------
Name | JUDITH A BROWN-RAY
-----------------------------------------------------
Credential | OTR/L
-----------------------------------------------------
Telephone | 561-352-4939
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225X00000X
-----------------------------------------------------
Taxonomy Name | Occupational Therapist
-----------------------------------------------------
License Number | OT6210
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------