Provider Demographics
NPI:1326162496
Name:ELMAZLOUM, MARTHA LUCIA (OTR)
Entity Type:Individual
Prefix:MRS
First Name:MARTHA
Middle Name:LUCIA
Last Name:ELMAZLOUM
Suffix:
Gender:F
Credentials:OTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3807 CHERRY GROVE CT
Mailing Address - Street 2:
Mailing Address - City:PORT ORANGE
Mailing Address - State:FL
Mailing Address - Zip Code:32129-8980
Mailing Address - Country:US
Mailing Address - Phone:386-760-9661
Mailing Address - Fax:
Practice Address - Street 1:170 N CENTER ST
Practice Address - Street 2:
Practice Address - City:ORMOND BEACH
Practice Address - State:FL
Practice Address - Zip Code:32174-5186
Practice Address - Country:US
Practice Address - Phone:386-672-7113
Practice Address - Fax:386-615-3621
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOT2729225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLOT2729OtherOTR LICENSE