=====================================================
General NPI Number Information
=====================================================
NPI Number | 1982827275
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | CORALYMAR CASANOVA
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/11/2007
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 301 S BAY ST
-----------------------------------------------------
City | EUSTIS
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32726-4005
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 180-033-0771
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 545 ONE CENTER BLVD APT 106
-----------------------------------------------------
City | ALTAMONTE SPRINGS
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32701-2207
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
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 | 12596
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------