Provider Demographics
NPI:1710563812
Name:BERMEO-LUCAS, ROXANA (OTR)
Entity type:Individual
Prefix:
First Name:ROXANA
Middle Name:
Last Name:BERMEO-LUCAS
Suffix:
Gender:F
Credentials:OTR
Other - Prefix:
Other - First Name:ROXANA
Other - Middle Name:G
Other - Last Name:BERMEO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:5150 PALM VALLEY RD STE 202
Mailing Address - Street 2:
Mailing Address - City:PONTE VEDRA BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32082-4630
Mailing Address - Country:US
Mailing Address - Phone:917-754-3019
Mailing Address - Fax:
Practice Address - Street 1:5150 PALM VALLEY RD STE 202
Practice Address - Street 2:
Practice Address - City:PONTE VEDRA BEACH
Practice Address - State:FL
Practice Address - Zip Code:32082-4630
Practice Address - Country:US
Practice Address - Phone:904-382-9790
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-03-20
Last Update Date:2021-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL21556225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist