Provider Demographics
NPI:1093350209
Name:HERRERA, CASEY MARIE (RBT, COTA)
Entity Type:Individual
Prefix:
First Name:CASEY
Middle Name:MARIE
Last Name:HERRERA
Suffix:
Gender:F
Credentials:RBT, COTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6500 JULIA DR
Mailing Address - Street 2:
Mailing Address - City:MILTON
Mailing Address - State:FL
Mailing Address - Zip Code:32570-3453
Mailing Address - Country:US
Mailing Address - Phone:325-642-0025
Mailing Address - Fax:
Practice Address - Street 1:3096 COLONIAL CIR
Practice Address - Street 2:
Practice Address - City:CRESTVIEW
Practice Address - State:FL
Practice Address - Zip Code:32539-8570
Practice Address - Country:US
Practice Address - Phone:307-221-2937
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-11-12
Last Update Date:2019-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
224Z00000X
FLRBT-19-105718106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
No224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant