Provider Demographics
NPI:1922630235
Name:LILEY, RICHARD SHOHEI (PTA, CLT)
Entity Type:Individual
Prefix:MR
First Name:RICHARD
Middle Name:SHOHEI
Last Name:LILEY
Suffix:
Gender:M
Credentials:PTA, CLT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12757 NEWFIELD DR
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32837-7435
Mailing Address - Country:US
Mailing Address - Phone:407-721-2024
Mailing Address - Fax:
Practice Address - Street 1:6000 TURKEY LAKE RD STE 203
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32819-4206
Practice Address - Country:US
Practice Address - Phone:407-352-3508
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-02-05
Last Update Date:2023-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL29983225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant