Provider Demographics
NPI:1326251737
Name:BURLEY, MANDY LEA
Entity Type:Individual
Prefix:
First Name:MANDY
Middle Name:LEA
Last Name:BURLEY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:MANDY
Other - Middle Name:LEA
Other - Last Name:DECKER
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:7709 GROVERIDGE CT
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32810-2729
Mailing Address - Country:US
Mailing Address - Phone:407-538-8765
Mailing Address - Fax:
Practice Address - Street 1:4448 EDGEWATER DR
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32804-1216
Practice Address - Country:US
Practice Address - Phone:407-531-3000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-08
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOT 9773225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist