Provider Demographics
NPI:1699108126
Name:PORTOGHESE, GRACE (OT)
Entity type:Individual
Prefix:
First Name:GRACE
Middle Name:
Last Name:PORTOGHESE
Suffix:
Gender:F
Credentials:OT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13540 17TH ST
Mailing Address - Street 2:
Mailing Address - City:DADE CITY
Mailing Address - State:FL
Mailing Address - Zip Code:33525-5244
Mailing Address - Country:US
Mailing Address - Phone:352-437-5151
Mailing Address - Fax:813-212-3870
Practice Address - Street 1:13540 17TH ST
Practice Address - Street 2:
Practice Address - City:DADE CITY
Practice Address - State:FL
Practice Address - Zip Code:33525-5244
Practice Address - Country:US
Practice Address - Phone:352-437-5151
Practice Address - Fax:813-212-3870
Is Sole Proprietor?:Yes
Enumeration Date:2013-08-20
Last Update Date:2023-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOT 15904225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist