Provider Demographics
NPI:1043602279
Name:GAVINS, AMBER ALEXANDREA
Entity Type:Individual
Prefix:
First Name:AMBER
Middle Name:ALEXANDREA
Last Name:GAVINS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1735 VINEYARD WAY
Mailing Address - Street 2:
Mailing Address - City:TALLAHASSEE
Mailing Address - State:FL
Mailing Address - Zip Code:32317-7914
Mailing Address - Country:US
Mailing Address - Phone:850-228-0859
Mailing Address - Fax:
Practice Address - Street 1:1735 VINEYARD WAY
Practice Address - Street 2:
Practice Address - City:TALLAHASSEE
Practice Address - State:FL
Practice Address - Zip Code:32317-7914
Practice Address - Country:US
Practice Address - Phone:850-228-0859
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-02-25
Last Update Date:2015-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL13889224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant