Provider Demographics
NPI:1619485562
Name:TYSON, SHANITA VENISE (COTA)
Entity Type:Individual
Prefix:
First Name:SHANITA
Middle Name:VENISE
Last Name:TYSON
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 1:4824 WATERS GATE DR
Mailing Address - Street 2:
Mailing Address - City:TAVARES
Mailing Address - State:FL
Mailing Address - Zip Code:32778-6208
Mailing Address - Country:US
Mailing Address - Phone:407-252-4249
Mailing Address - Fax:
Practice Address - Street 1:6 N EUSTIS ST
Practice Address - Street 2:
Practice Address - City:EUSTIS
Practice Address - State:FL
Practice Address - Zip Code:32726-3408
Practice Address - Country:US
Practice Address - Phone:321-276-5054
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-01-12
Last Update Date:2021-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOTA15370225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist