Provider Demographics
NPI:1407140155
Name:SMITH, KRISTY L (COTA/L)
Entity Type:Individual
Prefix:
First Name:KRISTY
Middle Name:L
Last Name:SMITH
Suffix:
Gender:F
Credentials:COTA/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2535 SHADOW VIEW CIR
Mailing Address - Street 2:
Mailing Address - City:MAITLAND
Mailing Address - State:FL
Mailing Address - Zip Code:32751-7517
Mailing Address - Country:US
Mailing Address - Phone:269-274-2123
Mailing Address - Fax:
Practice Address - Street 1:2535 SHADOW VIEW CIR
Practice Address - Street 2:
Practice Address - City:MAITLAND
Practice Address - State:FL
Practice Address - Zip Code:32751-7517
Practice Address - Country:US
Practice Address - Phone:269-274-2123
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-05-29
Last Update Date:2011-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOTA 10570172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker