MEDICARE: ANTOINETTE MARIE GORTZ OTR

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	OT13049	FL

General Provider Information

NPI Number	:	1285916692
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ANTOINETTE MARIE GORTZ OTR

Provider Business Mailing Address
First Line	:	5326 KULA CT
Second Line	:
City	:	NORTH PORT
State	:	FL
Zip	:	34287-2448
Country	:	US
Telephone Number	:	216-339-3586
Fax Number	:

Provider Business Practice Location Address
First Line	:	5326 KULA CT
Second Line	:
City	:	NORTH PORT
State	:	FL
Zip	:	34287-2448
Country	:	US
Telephone Number	:	216-339-3586
Fax Number	:

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

Provider Enumeration Date	:	09/12/2011
Last Update Date	:	09/12/2011

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