Basic Information
| Provider Information | |||||||||
| NPI: | 1770599763 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SAMUELSON | ||||||||
| FirstName: | LESLIE | ||||||||
| MiddleName: | JOYCE | ||||||||
| NamePrefix: | MRS. | ||||||||
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| Credential: | OTR | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6415 NW 56TH LN | ||||||||
| Address2: | |||||||||
| City: | GAINESVILLE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 326533114 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3523761611 | ||||||||
| FaxNumber: | 3523794055 | ||||||||
| Practice Location | |||||||||
| Address1: | 1601 SW ARCHER RD | ||||||||
| Address2: | HBPC 11I | ||||||||
| City: | GAINESVILLE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 326081135 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2533761611 | ||||||||
| FaxNumber: | 3523794055 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/31/2006 | ||||||||
| LastUpdateDate: | 06/04/2013 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | OT866 | FL | N | Other Service Providers | Specialist | 225X00000X | OT0866 | FL | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist |
No ID Information.