Provider Demographics
NPI:1841749421
Name:GULLETT, ELISABETH (OTR/L)
Entity Type:Individual
Prefix:
First Name:ELISABETH
Middle Name:
Last Name:GULLETT
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 1:9421 W PARK VILLAGE DR
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33626-5148
Mailing Address - Country:US
Mailing Address - Phone:703-935-9376
Mailing Address - Fax:
Practice Address - Street 1:9421 W PARK VILLAGE DR
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33626-5148
Practice Address - Country:US
Practice Address - Phone:703-935-9376
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-09-24
Last Update Date:2022-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOT17864225X00000X
FLOT 17864225XP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
No225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL018697200Medicaid