Provider Demographics
NPI:1346384617
Name:BANTA, KATHLEEN ELLEN (OTR)
Entity Type:Individual
Prefix:MRS
First Name:KATHLEEN
Middle Name:ELLEN
Last Name:BANTA
Suffix:
Gender:F
Credentials:OTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2910 SE 7TH ST
Mailing Address - Street 2:
Mailing Address - City:OCALA
Mailing Address - State:FL
Mailing Address - Zip Code:34471-2768
Mailing Address - Country:US
Mailing Address - Phone:352-620-2272
Mailing Address - Fax:352-620-2272
Practice Address - Street 1:2910 SE 7TH ST
Practice Address - Street 2:
Practice Address - City:OCALA
Practice Address - State:FL
Practice Address - Zip Code:34471-2768
Practice Address - Country:US
Practice Address - Phone:352-620-2272
Practice Address - Fax:352-620-2272
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-19
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOT354225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLZ1623OtherBLUE CROSS BLUE SHIELD