Provider Demographics
NPI:1407250517
Name:ANDERSON, CHRISTINE (COTA/L)
Entity Type:Individual
Prefix:
First Name:CHRISTINE
Middle Name:
Last Name:ANDERSON
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 1:2225 LONGMORE CIR
Mailing Address - Street 2:
Mailing Address - City:VALRICO
Mailing Address - State:FL
Mailing Address - Zip Code:33596-7835
Mailing Address - Country:US
Mailing Address - Phone:813-748-2255
Mailing Address - Fax:
Practice Address - Street 1:1445 HOWELL AVE
Practice Address - Street 2:
Practice Address - City:BROOKSVILLE
Practice Address - State:FL
Practice Address - Zip Code:34601-1502
Practice Address - Country:US
Practice Address - Phone:352-799-1451
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-10-17
Last Update Date:2014-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOTA13496224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant