Provider Demographics
NPI:1578687117
Name:FORMY-DUVAL, ELIZABETH A (OT)
Entity Type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:A
Last Name:FORMY-DUVAL
Suffix:
Gender:F
Credentials:OT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5831 BEE RIDGE RD STE 300
Mailing Address - Street 2:
Mailing Address - City:SARASOTA
Mailing Address - State:FL
Mailing Address - Zip Code:34233-5090
Mailing Address - Country:US
Mailing Address - Phone:941-782-0102
Mailing Address - Fax:941-794-1863
Practice Address - Street 1:5831 BEE RIDGE RD STE 300
Practice Address - Street 2:
Practice Address - City:SARASOTA
Practice Address - State:FL
Practice Address - Zip Code:34233-5090
Practice Address - Country:US
Practice Address - Phone:941-378-5100
Practice Address - Fax:941-960-1962
Is Sole Proprietor?:No
Enumeration Date:2007-03-19
Last Update Date:2019-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOT6623225X00000X, 225XH1200X, 225XH1200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
No225XH1200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistHand
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLOT6623OtherSTATE LICENSE