Basic Information
| Provider Information | |||||||||
| NPI: | 1780214908 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BURNETT | ||||||||
| FirstName: | MARY | ||||||||
| MiddleName: | KATHERINE | ||||||||
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| Credential: | OTR/L | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4256 SHORECREST DR | ||||||||
| Address2: | |||||||||
| City: | ORLANDO | ||||||||
| State: | FL | ||||||||
| PostalCode: | 328042235 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9046874810 | ||||||||
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| Practice Location | |||||||||
| Address1: | 455 W WARREN AVE STE 200 | ||||||||
| Address2: | |||||||||
| City: | LONGWOOD | ||||||||
| State: | FL | ||||||||
| PostalCode: | 327504038 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4072600551 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 01/16/2020 | ||||||||
| LastUpdateDate: | 01/16/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 01/16/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225XP0200X | 20578 | FL | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist | Pediatrics | 225X00000X | 20578 | FL | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist |
No ID Information.