Provider Demographics
NPI:1710071220
Name:SIMPO, DETRA SHAUNTEL (OTR/L)
Entity Type:Individual
Prefix:
First Name:DETRA
Middle Name:SHAUNTEL
Last Name:SIMPO
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:518 DRY BRANCH WAY
Mailing Address - Street 2:
Mailing Address - City:ST JOHNS
Mailing Address - State:FL
Mailing Address - Zip Code:32259-6203
Mailing Address - Country:US
Mailing Address - Phone:904-382-7886
Mailing Address - Fax:
Practice Address - Street 1:518 DRY BRANCH WAY
Practice Address - Street 2:
Practice Address - City:ST JOHNS
Practice Address - State:FL
Practice Address - Zip Code:32259-6203
Practice Address - Country:US
Practice Address - Phone:904-382-7886
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-02
Last Update Date:2020-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOT9940225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLZ9346OtherBCBS
FL024815600Medicaid