MEDICARE: DR. THERESA RENE PANTANELLA OT/L, MPA, OTD

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
1	225X00000X	Occupational Therapist	0002000	FL

General Provider Information

NPI Number	:	1215995303
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. THERESA RENE PANTANELLA OT/L, MPA, OTD

Provider Business Mailing Address
First Line	:	360 SE 5TH CT
Second Line	:
City	:	POMPANO BEACH
State	:	FL
Zip	:	33060-8465
Country	:	US
Telephone Number	:	954-785-8229
Fax Number	:	954-785-9227

Provider Business Practice Location Address
First Line	:	3221 NW 10TH TER
Second Line	:
City	:	FORT LAUDERDALE
State	:	FL
Zip	:	33309-5942
Country	:	US
Telephone Number	:	954-785-8229
Fax Number	:	954-785-9227

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/01/2006
Last Update Date	:	07/08/2007

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