Basic Information
| Provider Information | |||||||||
| NPI: | 1487110862 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SCANLON | ||||||||
| FirstName: | KIMBERLY | ||||||||
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| Credential: | MOT, OTR/L | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2301 SW 85TH WAY | ||||||||
| Address2: | |||||||||
| City: | DAVIE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 333245360 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5013883528 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1 OAKWOOD BLVD STE 130 | ||||||||
| Address2: | |||||||||
| City: | HOLLYWOOD | ||||||||
| State: | FL | ||||||||
| PostalCode: | 330201937 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9549253844 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 02/11/2019 | ||||||||
| LastUpdateDate: | 02/16/2019 | ||||||||
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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 | 225XP0200X | 19787 | FL | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 889063300 | 05 | FL | MEDICAID |