Provider Demographics
NPI:1235784521
Name:CHARLES-MALCOLM, PAULENE (OTD)
Entity Type:Individual
Prefix:
First Name:PAULENE
Middle Name:
Last Name:CHARLES-MALCOLM
Suffix:
Gender:F
Credentials:OTD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:260 1ST AVE S STE 200
Mailing Address - Street 2:
Mailing Address - City:SAINT PETERSBURG
Mailing Address - State:FL
Mailing Address - Zip Code:33701-4364
Mailing Address - Country:US
Mailing Address - Phone:727-803-1102
Mailing Address - Fax:
Practice Address - Street 1:771 CARPENTERS WAY
Practice Address - Street 2:
Practice Address - City:LAKELAND
Practice Address - State:FL
Practice Address - Zip Code:33809-3922
Practice Address - Country:US
Practice Address - Phone:727-803-1102
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-08-05
Last Update Date:2019-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOT20113225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist