Provider Demographics
NPI:1508116302
Name:LOOMIS, KRYSTAL (COTA)
Entity Type:Individual
Prefix:MRS
First Name:KRYSTAL
Middle Name:
Last Name:LOOMIS
Suffix:
Gender:F
Credentials:COTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4008 FONSECA AVE
Mailing Address - Street 2:
Mailing Address - City:SEBRING
Mailing Address - State:FL
Mailing Address - Zip Code:33872-2348
Mailing Address - Country:US
Mailing Address - Phone:863-253-1015
Mailing Address - Fax:
Practice Address - Street 1:725 S PINE ST
Practice Address - Street 2:
Practice Address - City:SEBRING
Practice Address - State:FL
Practice Address - Zip Code:33870-3654
Practice Address - Country:US
Practice Address - Phone:863-385-0161
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-09-19
Last Update Date:2019-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOTA12873224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant