Basic Information
| Provider Information | |||||||||
| NPI: | 1124072947 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | INDEPENDENT LIVING INC. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6508 GUNN HWY | ||||||||
| Address2: | |||||||||
| City: | TAMPA | ||||||||
| State: | FL | ||||||||
| PostalCode: | 336254022 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8139636923 | ||||||||
| FaxNumber: | 8132640768 | ||||||||
| Practice Location | |||||||||
| Address1: | 6508 GUNN HWY | ||||||||
| Address2: | |||||||||
| City: | TAMPA | ||||||||
| State: | FL | ||||||||
| PostalCode: | 336254022 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8139636923 | ||||||||
| FaxNumber: | 8132640768 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/19/2006 | ||||||||
| LastUpdateDate: | 01/29/2019 | ||||||||
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| AuthorizedOfficialLastName: | HARRIS | ||||||||
| AuthorizedOfficialFirstName: | STEPHANIE | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 8139636923 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | OTR | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103K00000X | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Behavioral Analyst | 106E00000X | N | 193200000X MULTI-SPECIALTY GROUP | 106S00000X | N | 193200000X MULTI-SPECIALTY GROUP | 225X00000X | OT4289 | FL | N | 193200000X MULTI-SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist | 225X00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist |
ID Information
| ID | Type | State | Issuer | Description | 884287600 | 05 | FL | MEDICAID |