MEDICARE: DANIELA MARISOL MABRY OTA

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	224Z00000X	Occupational Therapy Assistant	18171	FL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	M160173897970	OTHER	FL	DRIVER'S LICENSE

General Provider Information

NPI Number	:	1508443623
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DANIELA MARISOL MABRY OTA

Provider Business Mailing Address
First Line	:	5031 LOBLOLLY BAY LN
Second Line	:
City	:	ORLANDO
State	:	FL
Zip	:	32829-8731
Country	:	US
Telephone Number	:	480-612-2617
Fax Number	:

Provider Business Practice Location Address
First Line	:	1935 STATE ROAD 436 STE 1005
Second Line	:
City	:	WINTER PARK
State	:	FL
Zip	:	32792-2244
Country	:	US
Telephone Number	:	407-629-9455
Fax Number	:	407-629-9438

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

Provider Enumeration Date	:	03/25/2021
Last Update Date	:	03/25/2021

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