Provider Demographics
NPI:1174029607
Name:CLITES, KOLBIE
Entity Type:Individual
Prefix:
First Name:KOLBIE
Middle Name:
Last Name:CLITES
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 1:33 W COLONIAL DR APT 3315
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32801-7313
Mailing Address - Country:US
Mailing Address - Phone:321-412-2869
Mailing Address - Fax:
Practice Address - Street 1:33 W COLONIAL DR APT 3315
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32801-7313
Practice Address - Country:US
Practice Address - Phone:321-412-2869
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-04-03
Last Update Date:2018-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL19137225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL712949Medicaid