Provider Demographics
| NPI: | 1104706837 |
|---|---|
| Name: | MOBILE LYMPHEDEMA CLINIC, LLC |
| Entity type: | Organization |
| Organization Name: | MOBILE LYMPHEDEMA CLINIC, LLC |
| Other - Org Name: | |
| Other - Org Type: | |
| Authorized Official - Title/Position: | CLINICIAN |
| Authorized Official - Prefix: | |
| Authorized Official - First Name: | JESSICA |
| Authorized Official - Middle Name: | COLLEEN |
| Authorized Official - Last Name: | BOOTHE |
| Authorized Official - Suffix: | |
| Authorized Official - Credentials: | MSOT, OTR/L, CLT |
| Authorized Official - Phone: | 850-803-6683 |
| Mailing Address - Street 1: | 804 PINE ALLEY ST |
| Mailing Address - Street 2: | |
| Mailing Address - City: | FORT WALTON BEACH |
| Mailing Address - State: | FL |
| Mailing Address - Zip Code: | 32547-1216 |
| Mailing Address - Country: | US |
| Mailing Address - Phone: | 850-803-6683 |
| Mailing Address - Fax: | 888-857-4412 |
| Practice Address - Street 1: | 804 PINE ALLEY ST |
| Practice Address - Street 2: | |
| Practice Address - City: | FORT WALTON BEACH |
| Practice Address - State: | FL |
| Practice Address - Zip Code: | 32547-1216 |
| Practice Address - Country: | US |
| Practice Address - Phone: | 850-803-6683 |
| Practice Address - Fax: | |
| EIN: | <UNAVAIL> |
| Is Organization Subpart?: | No |
| Parent Organization LBN: | |
| Parent Organization TIN: | |
| Enumeration Date: | 2025-09-04 |
| Last Update Date: | 2025-11-25 |
| Deactivation Date: | |
| Deactivation Code: | |
| Reactivation Date: |
Provider Taxonomies
| Primary? | Code | Type | Classification | Specialization | Group |
|---|---|---|---|---|---|
| Yes | 225X00000X | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist | Group - Multi-Specialty | |
| No | 225XG0600X | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist | Gerontology | Group - Multi-Specialty |
| No | 225XE1200X | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist | Ergonomics | Group - Multi-Specialty |
| No | 225XP0019X | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist | Physical Rehabilitation | Group - Multi-Specialty |
| No | 225XE0001X | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist | Environmental Modification | Group - Multi-Specialty |
| No | 225400000X | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Rehabilitation Practitioner | Group - Multi-Specialty | |
| No | 225XH1200X | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist | Hand | Group - Multi-Specialty |
