Provider Demographics
NPI:1457435455
Name:EZELL, EDITH SELDEN (OTR/L)
Entity type:Individual
Prefix:
First Name:EDITH
Middle Name:SELDEN
Last Name:EZELL
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 1:501 BLACKWATER RUN
Mailing Address - Street 2:
Mailing Address - City:NICEVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32578-1642
Mailing Address - Country:US
Mailing Address - Phone:850-678-6400
Mailing Address - Fax:
Practice Address - Street 1:4 JACKSON ST NE
Practice Address - Street 2:
Practice Address - City:FORT WALTON BEACH
Practice Address - State:FL
Practice Address - Zip Code:32548-4925
Practice Address - Country:US
Practice Address - Phone:850-862-7227
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL9614225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLOT10239OtherFLORIDA LICENSE (OT)