Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 225XG0600X | Occupational Therapist - Gerontology | OT17824 | FL |
NPI | 1164007399 |
---|---|
Provider Name | Douglas Faas |
First Address | Fort Myers, FL 33901-2465 |
Second Address | Ft. Myers, FL 33901 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 09/03/2021 |
Last Update Date | 09/03/2021 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
123456789 | (05) | FL |