Basic Information
| Provider Information | |||||||||
| NPI: | 1407493554 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MIFSUD | ||||||||
| FirstName: | MICHAEL | ||||||||
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| Credential: | COTA/L | ||||||||
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| Mailing Information | |||||||||
| Address1: | 520 WICKHAM LAKES DR | ||||||||
| Address2: | |||||||||
| City: | MELBOURNE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 329402216 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3212434605 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1535 COGSWELL ST STE C24 | ||||||||
| Address2: | |||||||||
| City: | ROCKLEDGE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 329552740 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3218728737 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 12/09/2019 | ||||||||
| LastUpdateDate: | 12/09/2019 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 12/09/2019 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 224Z00000X | 17299 | FL | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapy Assistant |
No ID Information.