MEDICARE: ISENBERG PEDIATRIC OCCUP THERAPY INC

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	OT2238	FL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1750449567
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ISENBERG PEDIATRIC OCCUP THERAPY INC

Provider Business Mailing Address
First Line	:	PO BOX 568
Second Line	:
City	:	LYNN HAVEN
State	:	FL
Zip	:	32444
Country	:	US
Telephone Number	:	850-258-6366
Fax Number	:	850-522-8022

Provider Business Practice Location Address
First Line	:	2685 JENKS AVE
Second Line	:
City	:	PANAMA CITY
State	:	FL
Zip	:	32405-4351
Country	:	US
Telephone Number	:	850-215-6788
Fax Number	:	850-215-6787

Authorized Official
Title or Position	:	OWNER
Name	:	MRS. SHELLEY ISENBERG HICKMAN
Credential	:	OTRL
Telephone Number	:	850-258-6366

Provider Enumeration Date	:	12/05/2006
Last Update Date	:	04/05/2016

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