Provider Demographics
NPI:1598041105
Name:CROSS, STEPHANIE BROOKE (COTA)
Entity Type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:BROOKE
Last Name:CROSS
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 1:25335 DARNOCH ST
Mailing Address - Street 2:
Mailing Address - City:SORRENTO
Mailing Address - State:FL
Mailing Address - Zip Code:32776-9655
Mailing Address - Country:US
Mailing Address - Phone:407-310-9662
Mailing Address - Fax:
Practice Address - Street 1:25335 DARNOCH ST
Practice Address - Street 2:
Practice Address - City:SORRENTO
Practice Address - State:FL
Practice Address - Zip Code:32776-9655
Practice Address - Country:US
Practice Address - Phone:407-310-9662
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-10-26
Last Update Date:2011-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOTA12027224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant