Provider Demographics
NPI:1033226865
Name:CASSELLA, LAN NGUYEN (OTR/L)
Entity Type:Individual
Prefix:
First Name:LAN
Middle Name:NGUYEN
Last Name:CASSELLA
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:LAN
Other - Middle Name:PHUONG
Other - Last Name:NGUYEN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:3421 W LEROY ST
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33607-1129
Mailing Address - Country:US
Mailing Address - Phone:813-846-5089
Mailing Address - Fax:813-441-8121
Practice Address - Street 1:3421 W LEROY ST
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33607-1129
Practice Address - Country:US
Practice Address - Phone:813-846-5089
Practice Address - Fax:813-441-8121
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-25
Last Update Date:2021-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOT5836225X00000X
FLOT 5836225XP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGroup - Single Specialty
No225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL885649400Medicaid