MEDICARE: MRS. ANTRELISE GANTT MS,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
1	225X00000X	Occupational Therapist	9286	FL

General Provider Information

NPI Number	:	1508059189
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. ANTRELISE GANTT MS,OTR/L

Provider Business Mailing Address
First Line	:	1820 NW 183RD ST
Second Line	:
City	:	MIAMI GARDENS
State	:	FL
Zip	:	33056-3838
Country	:	US
Telephone Number	:	305-626-8836
Fax Number	:	305-626-8838

Provider Business Practice Location Address
First Line	:	1820 NW 183RD ST
Second Line	:
City	:	MIAMI GARDENS
State	:	FL
Zip	:	33056-3838
Country	:	US
Telephone Number	:	305-626-8836
Fax Number	:	305-626-8838

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

Provider Enumeration Date	:	08/27/2007
Last Update Date	:	08/27/2007

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