Provider Demographics
NPI:1174190417
Name:BURGEESS, ALEXA MIKAEL (COTA/L, CSRS, CNS)
Entity Type:Individual
Prefix:
First Name:ALEXA
Middle Name:MIKAEL
Last Name:BURGEESS
Suffix:
Gender:F
Credentials:COTA/L, CSRS, CNS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:34 AMERICAN CT
Mailing Address - Street 2:
Mailing Address - City:SANTA ROSA BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32459-5099
Mailing Address - Country:US
Mailing Address - Phone:740-645-1905
Mailing Address - Fax:
Practice Address - Street 1:4595 E HIGHWAY 20
Practice Address - Street 2:
Practice Address - City:NICEVILLE
Practice Address - State:FL
Practice Address - Zip Code:32578-8847
Practice Address - Country:US
Practice Address - Phone:850-460-3598
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-06-07
Last Update Date:2021-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOTA16815224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant