Provider Demographics
NPI:1902176803
Name:VESGA, MAUREEN THERESA (OTR/L)
Entity Type:Individual
Prefix:
First Name:MAUREEN
Middle Name:THERESA
Last Name:VESGA
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:MAUREEN
Other - Middle Name:THERESA
Other - Last Name:DYER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:702 S KINGS AVE
Mailing Address - Street 2:
Mailing Address - City:BRANDON
Mailing Address - State:FL
Mailing Address - Zip Code:33511-5925
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:702 S KINGS AVE
Practice Address - Street 2:
Practice Address - City:BRANDON
Practice Address - State:FL
Practice Address - Zip Code:33511-5925
Practice Address - Country:US
Practice Address - Phone:813-651-1818
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-01-09
Last Update Date:2017-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOT14750225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist