MEDICARE: BRUNETTE ST VICTOR

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	OTA3256	CA
2	224Z00000X	Occupational Therapy Assistant	14229	FL

General Provider Information

NPI Number	:	1538541248
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	BRUNETTE ST VICTOR

Provider Business Mailing Address
First Line	:	1170 SUSSEX DR APT 1103
Second Line	:
City	:	NORTH LAUDERDALE
State	:	FL
Zip	:	33068-5326
Country	:	US
Telephone Number	:	954-708-6311
Fax Number	:

Provider Business Practice Location Address
First Line	:	1170 SUSSEX DR APT 1103
Second Line	:
City	:	NORTH LAUDERDALE
State	:	FL
Zip	:	33068-5326
Country	:	US
Telephone Number	:	954-708-6311
Fax Number	:

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

Provider Enumeration Date	:	06/18/2015
Last Update Date	:	10/23/2018

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Directions to “ BRUNETTE ST VICTOR ” Practice Location

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