Provider Demographics
NPI:1720395759
Name:TRIPLE E OT, INC
Entity Type:Organization
Organization Name:TRIPLE E OT, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OCCUPATIONAL THERAPIST/DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:KIM
Authorized Official - Middle Name:E
Authorized Official - Last Name:HYDLE
Authorized Official - Suffix:
Authorized Official - Credentials:OTR/L
Authorized Official - Phone:850-682-8388
Mailing Address - Street 1:4100 S FERDON BLVD
Mailing Address - Street 2:SUITE C-1
Mailing Address - City:CRESTVIEW
Mailing Address - State:FL
Mailing Address - Zip Code:32536-5252
Mailing Address - Country:US
Mailing Address - Phone:850-682-8388
Mailing Address - Fax:
Practice Address - Street 1:450 LAKEVIEW DR
Practice Address - Street 2:
Practice Address - City:DEFUNIAK SPRINGS
Practice Address - State:FL
Practice Address - Zip Code:32433-4058
Practice Address - Country:US
Practice Address - Phone:850-401-1227
Practice Address - Fax:850-892-6994
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-09-13
Last Update Date:2010-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOT5156225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL000124300Medicaid