MEDICARE: SHINING STAR THERAPY LLC

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	225XP0200X	Pediatric Occupational Therapist	14821	FL

General Provider Information

NPI Number	:	1457632606
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SHINING STAR THERAPY LLC

Provider Business Mailing Address
First Line	:	8341 OLD TOWN DR
Second Line	:
City	:	TAMPA
State	:	FL
Zip	:	33647-3335
Country	:	US
Telephone Number	:	708-715-2555
Fax Number	:	708-221-6638

Provider Business Practice Location Address
First Line	:	8341 OLD TOWN DR
Second Line	:
City	:	TAMPA
State	:	FL
Zip	:	33647-3335
Country	:	US
Telephone Number	:	708-715-2555
Fax Number	:	708-221-6638

Authorized Official
Title or Position	:	MEMBER
Name	:	MRS. MYLENE BRAGGS
Credential	:	OTR/L
Telephone Number	:	708-715-2555

Provider Enumeration Date	:	09/01/2011
Last Update Date	:	09/01/2011

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