Provider Demographics
NPI:1518698877
Name:LASTINGER, MARY TUCKER (OTR/L)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:TUCKER
Last Name:LASTINGER
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1605 ATTAPULGUS HWY
Mailing Address - Street 2:
Mailing Address - City:QUINCY
Mailing Address - State:FL
Mailing Address - Zip Code:32352-0914
Mailing Address - Country:US
Mailing Address - Phone:850-597-6279
Mailing Address - Fax:
Practice Address - Street 1:6135 WILLIAMS RD
Practice Address - Street 2:
Practice Address - City:TALLAHASSEE
Practice Address - State:FL
Practice Address - Zip Code:32311-9107
Practice Address - Country:US
Practice Address - Phone:850-294-9716
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-06-17
Last Update Date:2022-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL23272225X00000X
FLOT23272225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist