Provider Demographics
NPI:1053650226
Name:NEAL, ELAINE (OTA12414)
Entity Type:Individual
Prefix:
First Name:ELAINE
Middle Name:
Last Name:NEAL
Suffix:
Gender:F
Credentials:OTA12414
Other - Prefix:
Other - First Name:ELAINE
Other - Middle Name:
Other - Last Name:MILLER-FAIN/MILLER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:179 BROYLES DR SE
Mailing Address - Street 2:
Mailing Address - City:PALM BAY
Mailing Address - State:FL
Mailing Address - Zip Code:32909-2350
Mailing Address - Country:US
Mailing Address - Phone:321-844-1010
Mailing Address - Fax:
Practice Address - Street 1:179 BROYLES DR SE
Practice Address - Street 2:
Practice Address - City:PALM BAY
Practice Address - State:FL
Practice Address - Zip Code:32909-2350
Practice Address - Country:US
Practice Address - Phone:321-844-1010
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-02-08
Last Update Date:2024-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOTA12414224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant