Provider Demographics
NPI:1366031643
Name:GOSS, KIM M (COTA)
Entity Type:Individual
Prefix:MRS
First Name:KIM
Middle Name:M
Last Name:GOSS
Suffix:
Gender:F
Credentials:COTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1050 OCEAN SHORE BLVD
Mailing Address - Street 2:
Mailing Address - City:ORMOND BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32176-4126
Mailing Address - Country:US
Mailing Address - Phone:386-441-1771
Mailing Address - Fax:
Practice Address - Street 1:1050 OCEAN SHORE BLVD
Practice Address - Street 2:
Practice Address - City:ORMOND BEACH
Practice Address - State:FL
Practice Address - Zip Code:32176-4126
Practice Address - Country:US
Practice Address - Phone:386-441-1771
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-01-12
Last Update Date:2021-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
224Z00000X
FLOTA13605224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant