MEDICARE: REGINA WELLS OT

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	23841	FL

General Provider Information

NPI Number	:	1245928514
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	REGINA WELLS OT

Provider Business Mailing Address
First Line	:	821 INDIAN RIVER AVE
Second Line	:
City	:	TITUSVILLE
State	:	FL
Zip	:	32780-4298
Country	:	US
Telephone Number	:	919-426-9555
Fax Number	:

Provider Business Practice Location Address
First Line	:	7000 SPYGLASS CT
Second Line	:
City	:	VIERA
State	:	FL
Zip	:	32940-8288
Country	:	US
Telephone Number	:	321-241-6543
Fax Number	:	321-241-6513

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

Provider Enumeration Date	:	04/25/2023
Last Update Date	:	04/25/2023

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