Provider Demographics
NPI:1174493423
Name:SIMON, MARYKAY RITA
Entity type:Individual
Prefix:
First Name:MARYKAY
Middle Name:RITA
Last Name:SIMON
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 1:910 S PALMETTO AVE
Mailing Address - Street 2:
Mailing Address - City:DAYTONA BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32114-5324
Mailing Address - Country:US
Mailing Address - Phone:386-299-6558
Mailing Address - Fax:
Practice Address - Street 1:910 S PALMETTO AVE
Practice Address - Street 2:
Practice Address - City:DAYTONA BEACH
Practice Address - State:FL
Practice Address - Zip Code:32114-5324
Practice Address - Country:US
Practice Address - Phone:386-299-6558
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-11-10
Last Update Date:2025-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOTA11262224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy AssistantGroup - Single Specialty