Basic Information
| Provider Information | |||||||||
| NPI: | 1104161090 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | PACHECO ORTA | ||||||||
| FirstName: | MARISELY | ||||||||
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| Credential: | MOTR/L | ||||||||
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| Mailing Information | |||||||||
| Address1: | 504 ORANGE DR APT 24 | ||||||||
| Address2: | |||||||||
| City: | ALTAMONTE SPRINGS | ||||||||
| State: | FL | ||||||||
| PostalCode: | 327015301 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4074885349 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1809 E BROADWAY ST STE 122 | ||||||||
| Address2: | |||||||||
| City: | OVIEDO | ||||||||
| State: | FL | ||||||||
| PostalCode: | 327658597 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4073595693 | ||||||||
| FaxNumber: | 4077925693 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/03/2012 | ||||||||
| LastUpdateDate: | 10/10/2017 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225X00000X | OT18324 | FL | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist |
No ID Information.