Provider Demographics
NPI:1477056653
Name:DEREQUITO, TONI ROSE (OTR)
Entity Type:Individual
Prefix:
First Name:TONI ROSE
Middle Name:
Last Name:DEREQUITO
Suffix:
Gender:F
Credentials:OTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:901 CLARK ST
Mailing Address - Street 2:
Mailing Address - City:OVIEDO
Mailing Address - State:FL
Mailing Address - Zip Code:32765-7378
Mailing Address - Country:US
Mailing Address - Phone:407-359-5693
Mailing Address - Fax:
Practice Address - Street 1:901 CLARK ST
Practice Address - Street 2:
Practice Address - City:OVIEDO
Practice Address - State:FL
Practice Address - Zip Code:32765-7378
Practice Address - Country:US
Practice Address - Phone:407-359-5693
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-03-14
Last Update Date:2023-05-05
Deactivation Date:2023-04-14
Deactivation Code:
Reactivation Date:2023-04-25
Provider Licenses
StateLicense IDTaxonomies
FLOTA15765224Z00000X
FLOT23756225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
No224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant