Provider Demographics
NPI:1366840563
Name:GILLIS, DONOVAN (COTA)
Entity Type:Individual
Prefix:
First Name:DONOVAN
Middle Name:
Last Name:GILLIS
Suffix:
Gender:M
Credentials:COTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1800 MICCOSUKEE COMMONS DR
Mailing Address - Street 2:APT 905
Mailing Address - City:TALLAHASSEE
Mailing Address - State:FL
Mailing Address - Zip Code:32308-5435
Mailing Address - Country:US
Mailing Address - Phone:850-508-5347
Mailing Address - Fax:
Practice Address - Street 1:1800 MICCOSUKEE COMMONS DR
Practice Address - Street 2:APT 905
Practice Address - City:TALLAHASSEE
Practice Address - State:FL
Practice Address - Zip Code:32308-5435
Practice Address - Country:US
Practice Address - Phone:850-508-5347
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-12-22
Last Update Date:2014-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOTA 13836224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant