Provider Demographics
NPI:1245495001
Name:FIELDS, TEQUILA
Entity type:Individual
Prefix:
First Name:TEQUILA
Middle Name:
Last Name:FIELDS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:501 E OAK ST
Mailing Address - Street 2:
Mailing Address - City:KISSIMMEE
Mailing Address - State:FL
Mailing Address - Zip Code:34744-4554
Mailing Address - Country:US
Mailing Address - Phone:407-957-0370
Mailing Address - Fax:
Practice Address - Street 1:501 E OAK ST
Practice Address - Street 2:
Practice Address - City:KISSIMMEE
Practice Address - State:FL
Practice Address - Zip Code:34744-4554
Practice Address - Country:US
Practice Address - Phone:407-957-0370
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-07-22
Last Update Date:2008-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOT9827225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist