MEDICARE: MRS. PAULA LESLEE BROSZ OT/L

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	225XG0600X	Gerontology Occupational Therapist	4713	FL
2	225X00000X	Occupational Therapist	4713	FL

General Provider Information

NPI Number	:	1245822519
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. PAULA LESLEE BROSZ OT/L

Provider Business Mailing Address
First Line	:	140 TELFORD DR
Second Line	:
City	:	SAINT JOHNS
State	:	FL
Zip	:	32259-8218
Country	:	US
Telephone Number	:	904-859-9648
Fax Number	:

Provider Business Practice Location Address
First Line	:	12350 SAN JOSE BLVD
Second Line	:
City	:	JACKSONVILLE
State	:	FL
Zip	:	32223-2800
Country	:	US
Telephone Number	:	904-584-9825
Fax Number	:

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

Provider Enumeration Date	:	02/09/2021
Last Update Date	:	02/09/2021

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