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NPI Code Detail

MEDICARE: EDITH SELDEN EZELL OTR/L

MEDICARE: EDITH SELDEN EZELL OTR/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
1225X00000XOccupational Therapist9614FL

Other Identifiers

# Provider Identifier Provider Identifier Type Provider Identifier State Provider Identifier Issuer
1OT10239OTHERFLFLORIDA LICENSE (OT)

General Provider Information

NPI Number : 1457435455
Entity Type Code : Individual
Provider Name (Legal Business Name) : EDITH SELDEN EZELL OTR/L
Provider Business Mailing Address
First Line : 501 BLACKWATER RUN
Second Line :
City : NICEVILLE
State : FL
Zip : 32578-1642
Country : US
Telephone Number : 850-678-6400
Fax Number :
Provider Business Practice Location Address
First Line : 4 JACKSON ST NE
Second Line :
City : FORT WALTON BEACH
State : FL
Zip : 32548-4925
Country : US
Telephone Number : 850-862-7227
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 10/25/2006
Last Update Date : 07/08/2007

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Directions to “ EDITH SELDEN EZELL OTR/L” Practice Location

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