Basic Information
| Provider Information | |||||||||
| NPI: | 1376162552 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SOUTHWELL | ||||||||
| FirstName: | BRIANNE | ||||||||
| MiddleName: | KRISTIN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 810 NE 12TH AVE | ||||||||
| Address2: | |||||||||
| City: | MULBERRY | ||||||||
| State: | FL | ||||||||
| PostalCode: | 338602826 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8638122863 | ||||||||
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| Practice Location | |||||||||
| Address1: | 4411 N HABANA AVE | ||||||||
| Address2: | |||||||||
| City: | TAMPA | ||||||||
| State: | FL | ||||||||
| PostalCode: | 336147211 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8138722771 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 04/08/2020 | ||||||||
| LastUpdateDate: | 04/08/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 04/08/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 224Z00000X | OTA17712 | FL | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapy Assistant |
No ID Information.