Provider Demographics
NPI:1013371806
Name:BANTA, DAVID JOSEPH (OTR/L)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:JOSEPH
Last Name:BANTA
Suffix:
Gender:M
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 1:2260 BRIDGEPORT CIR
Mailing Address - Street 2:
Mailing Address - City:ROCKLEDGE
Mailing Address - State:FL
Mailing Address - Zip Code:32955-4344
Mailing Address - Country:US
Mailing Address - Phone:321-427-0046
Mailing Address - Fax:
Practice Address - Street 1:2260 BRIDGEPORT CIR
Practice Address - Street 2:
Practice Address - City:ROCKLEDGE
Practice Address - State:FL
Practice Address - Zip Code:32955-4344
Practice Address - Country:US
Practice Address - Phone:321-427-0046
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-04-07
Last Update Date:2018-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOT 17634225XP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatrics