Provider Demographics
NPI:1225430903
Name:BANTA, CAYLEE JACQUELYN (OTD, OTR/L)
Entity Type:Individual
Prefix:
First Name:CAYLEE
Middle Name:JACQUELYN
Last Name:BANTA
Suffix:
Gender:F
Credentials:OTD, OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2260 BRIDGEPORT CIR
Mailing Address - Street 2:
Mailing Address - City:ROCKLEDGE
Mailing Address - State:FL
Mailing Address - Zip Code:32955-4344
Mailing Address - Country:US
Mailing Address - Phone:321-446-2742
Mailing Address - Fax:
Practice Address - Street 1:2260 BRIDGEPORT CIR
Practice Address - Street 2:
Practice Address - City:ROCKLEDGE
Practice Address - State:FL
Practice Address - Zip Code:32955
Practice Address - Country:US
Practice Address - Phone:321-446-2742
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-09-24
Last Update Date:2018-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOT15225225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL1225430903Medicaid