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NPI Code Detail

MEDICARE: SHANE BRADLEY OTA

MEDICARE: SHANE BRADLEY OTA
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
1224Z00000XOccupational Therapy AssistantOTA17590FL

General Provider Information

NPI Number : 1093348922
Entity Type Code : Individual
Provider Name (Legal Business Name) : SHANE BRADLEY OTA
Provider Business Mailing Address
First Line : 8477 S SUNCOAST BLVD
Second Line :
City : HOMOSASSA
State : FL
Zip : 34446-5028
Country : US
Telephone Number : 352-382-7214
Fax Number : 352-382-7781
Provider Business Practice Location Address
First Line : 1100 S COURTENAY PKWY
Second Line :
City : MERRITT ISLAND
State : FL
Zip : 32952-3804
Country : US
Telephone Number : 321-452-1233
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 02/19/2020
Last Update Date : 02/19/2020

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