Provider Demographics
NPI:1780170498
Name:BACK 2 BASICS OT, LLC
Entity type:Organization
Organization Name:BACK 2 BASICS OT, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:SOLINA
Authorized Official - Middle Name:
Authorized Official - Last Name:BRAININ-MATTOS
Authorized Official - Suffix:
Authorized Official - Credentials:OTR/L
Authorized Official - Phone:407-376-2592
Mailing Address - Street 1:134 HONORS WAY
Mailing Address - Street 2:
Mailing Address - City:WINTER SPRINGS
Mailing Address - State:FL
Mailing Address - Zip Code:32708-6352
Mailing Address - Country:US
Mailing Address - Phone:407-376-2592
Mailing Address - Fax:407-369-4221
Practice Address - Street 1:134 HONORS WAY
Practice Address - Street 2:
Practice Address - City:WINTER SPRINGS
Practice Address - State:FL
Practice Address - Zip Code:32708-6352
Practice Address - Country:US
Practice Address - Phone:407-376-2592
Practice Address - Fax:407-369-4221
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-07-05
Last Update Date:2018-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOT14072225XP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatricsGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL1043503485Medicaid