Basic Information
| Provider Information | |||||||||
| NPI: | 1023023371 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BOSSET | ||||||||
| FirstName: | LORI | ||||||||
| MiddleName: | ANN | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | OTR/L | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | MACDONALD | ||||||||
| OtherFirstName: | LORI | ||||||||
| OtherMiddleName: | ANN | ||||||||
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| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 1200 LEXINGTON GREEN LN | ||||||||
| Address2: | |||||||||
| City: | SANFORD | ||||||||
| State: | FL | ||||||||
| PostalCode: | 327711013 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3862264537 | ||||||||
| FaxNumber: | 4073223442 | ||||||||
| Practice Location | |||||||||
| Address1: | 290 CLYDE MORRIS BLVD STE A1 | ||||||||
| Address2: | |||||||||
| City: | ORMOND BEACH | ||||||||
| State: | FL | ||||||||
| PostalCode: | 32174 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3868980443 | ||||||||
| FaxNumber: | 3868980459 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/29/2006 | ||||||||
| LastUpdateDate: | 10/03/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225X00000X | OT6537 | FL | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist |
ID Information
| ID | Type | State | Issuer | Description | 892521600 | 05 | FL | MEDICAID | Z134D | 01 | FL | BLUE CROSS BLUE SHIELD FL | OTHER |