Provider Demographics
NPI:1225422058
Name:FARRELL, LILLIAN BLACKMON (OTR/L)
Entity Type:Individual
Prefix:
First Name:LILLIAN
Middle Name:BLACKMON
Last Name:FARRELL
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:LILLIAN
Other - Middle Name:ELIZABETH
Other - Last Name:BLACKMON
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:5917 TAYWOOD DRIVE
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33624
Mailing Address - Country:US
Mailing Address - Phone:772-418-9240
Mailing Address - Fax:813-264-0768
Practice Address - Street 1:6508 GUNN HWY
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33625-4022
Practice Address - Country:US
Practice Address - Phone:813-963-6923
Practice Address - Fax:813-264-0768
Is Sole Proprietor?:No
Enumeration Date:2015-03-18
Last Update Date:2021-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOT 16903225X00000X
FLOT16903225XP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatrics
No225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL14039460OtherCAQH
FL014555100Medicaid