Provider Demographics
NPI:1275520249
Name:ENAULT, ALICE M (OT)
Entity Type:Individual
Prefix:
First Name:ALICE
Middle Name:M
Last Name:ENAULT
Suffix:
Gender:F
Credentials:OT
Other - Prefix:
Other - First Name:ALICE
Other - Middle Name:M
Other - Last Name:SHAFFER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OTR/L
Mailing Address - Street 1:250 AVENUE K. SW
Mailing Address - Street 2:SUITE 200
Mailing Address - City:WINTER HAVEN
Mailing Address - State:FL
Mailing Address - Zip Code:33880-3919
Mailing Address - Country:US
Mailing Address - Phone:863-297-5400
Mailing Address - Fax:863-293-8230
Practice Address - Street 1:250 AVENUE K. SW
Practice Address - Street 2:SUITE 200
Practice Address - City:WINTER HAVEN
Practice Address - State:FL
Practice Address - Zip Code:33880-3919
Practice Address - Country:US
Practice Address - Phone:863-297-5400
Practice Address - Fax:863-293-8230
Is Sole Proprietor?:No
Enumeration Date:2005-10-04
Last Update Date:2010-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOT8245225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLZ043TOtherBLUE CROSS/BLUE SHIELD
E7957ZP66362Medicare UPIN
FLZ043TOtherBLUE CROSS/BLUE SHIELD
E7957ZMedicare PIN
FLE7957YMedicare ID - Type UnspecifiedMEDICARE