Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 225XP0200X | Occupational Therapist - Pediatrics | OT10194 | FL |
NPI | 1013024686 |
---|---|
Provider Name | Lidu Ivette Potter |
First Address | Palm, FL 34683-5363 |
Second Address | Palm Harbor, FL 34683-5235 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 23/08/2006 |
Last Update Date | 09/08/2017 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
887471900 | (05) | FL |