Provider Demographics
NPI:1376285718
Name:GAUTHIER, THARA (BHSC , COTA/L)
Entity Type:Individual
Prefix:
First Name:THARA
Middle Name:
Last Name:GAUTHIER
Suffix:
Gender:F
Credentials:BHSC , COTA/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:385 SAN MARINO RD SW
Mailing Address - Street 2:
Mailing Address - City:PALM BAY
Mailing Address - State:FL
Mailing Address - Zip Code:32908-3334
Mailing Address - Country:US
Mailing Address - Phone:321-987-7989
Mailing Address - Fax:
Practice Address - Street 1:900 S BABCOCK ST
Practice Address - Street 2:
Practice Address - City:MELBOURNE
Practice Address - State:FL
Practice Address - Zip Code:32901-1853
Practice Address - Country:US
Practice Address - Phone:321-409-4800
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-04-07
Last Update Date:2022-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL18829224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant