Basic Information
| Provider Information | |||||||||
| NPI: | 1790253292 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | D'AZZO | ||||||||
| FirstName: | LAUREN | ||||||||
| MiddleName: | CHRISTINE | ||||||||
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| Credential: | COTA/L | ||||||||
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| Mailing Information | |||||||||
| Address1: | 14904 ABAIR ST | ||||||||
| Address2: | |||||||||
| City: | HUDSON | ||||||||
| State: | FL | ||||||||
| PostalCode: | 346674248 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 1114 CHATMAN BLVD | ||||||||
| Address2: | |||||||||
| City: | BROOKSVILLE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 346013104 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3527966701 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 11/02/2018 | ||||||||
| LastUpdateDate: | 11/02/2018 | ||||||||
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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 | 224Z00000X | OTA15775 | FL | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapy Assistant |
ID Information
| ID | Type | State | Issuer | Description | RET824478470 | 01 | FL | BLUE CROSS BLUE SHIELD | OTHER |