MEDICARE: MRS. TAIMI SANTISTEBAN SOSA OT

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	OT 18289	FL
2	225XP0200X	Pediatric Occupational Therapist	0119009094	VA

General Provider Information

NPI Number	:	1790064756
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. TAIMI SANTISTEBAN SOSA OT

Provider Business Mailing Address
First Line	:	3342 CIRCLE BROOK DR APT H
Second Line	:
City	:	ROANOKE
State	:	VA
Zip	:	24018-7250
Country	:	US
Telephone Number	:	786-219-5024
Fax Number	:

Provider Business Practice Location Address
First Line	:	3342 CIRCLE BROOK DR APT H
Second Line	:
City	:	ROANOKE
State	:	VA
Zip	:	24018-7250
Country	:	US
Telephone Number	:	786-219-5024
Fax Number	:

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

Provider Enumeration Date	:	08/09/2011
Last Update Date	:	02/09/2022

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