MEDICARE: LIFE ENRICHMENT & WELLNESS

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	OT13709	FL

General Provider Information

NPI Number	:	1255825055
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LIFE ENRICHMENT & WELLNESS

Provider Business Mailing Address
First Line	:	552 10TH PL
Second Line	:
City	:	VERO BEACH
State	:	FL
Zip	:	32960-6823
Country	:	US
Telephone Number	:	772-494-3010
Fax Number	:

Provider Business Practice Location Address
First Line	:	552 10TH PL
Second Line	:
City	:	VERO BEACH
State	:	FL
Zip	:	32960
Country	:	US
Telephone Number	:	772-494-3010
Fax Number	:

Authorized Official
Title or Position	:	OCCUPATIONAL THERAPIST
Name	:	CAROL ANN DEFAZIO
Credential	:	MSOTR
Telephone Number	:	772-494-3010

Provider Enumeration Date	:	06/15/2018
Last Update Date	:	08/09/2018

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