Provider Demographics
NPI:1154845253
Name:PEDERSEN, CALLIE BLAKE (MOT, OTR/L)
Entity Type:Individual
Prefix:
First Name:CALLIE
Middle Name:BLAKE
Last Name:PEDERSEN
Suffix:
Gender:F
Credentials:MOT, OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7265 MARTIN RD
Mailing Address - Street 2:
Mailing Address - City:MILTON
Mailing Address - State:FL
Mailing Address - Zip Code:32570-5509
Mailing Address - Country:US
Mailing Address - Phone:318-332-5211
Mailing Address - Fax:
Practice Address - Street 1:7265 MARTIN RD
Practice Address - Street 2:
Practice Address - City:MILTON
Practice Address - State:FL
Practice Address - Zip Code:32570-5509
Practice Address - Country:US
Practice Address - Phone:318-332-5211
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-07-31
Last Update Date:2021-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL18016225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist