Provider Demographics
NPI:1639550387
Name:LARGACHA, KEILY (COTA/L)
Entity Type:Individual
Prefix:
First Name:KEILY
Middle Name:
Last Name:LARGACHA
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 1:2608 COLDSTREAM CT
Mailing Address - Street 2:
Mailing Address - City:KISSIMMEE
Mailing Address - State:FL
Mailing Address - Zip Code:34743-5659
Mailing Address - Country:US
Mailing Address - Phone:407-738-3465
Mailing Address - Fax:
Practice Address - Street 1:3201 BUDINGER AVE
Practice Address - Street 2:
Practice Address - City:SAINT CLOUD
Practice Address - State:FL
Practice Address - Zip Code:34769-7203
Practice Address - Country:US
Practice Address - Phone:407-891-3082
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-06-17
Last Update Date:2015-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL12537224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant