Provider Demographics
NPI:1790240703
Name:GROWDEN, KIRSTEN FAITH (COTA)
Entity Type:Individual
Prefix:
First Name:KIRSTEN
Middle Name:FAITH
Last Name:GROWDEN
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 1:14805 CAPE DR E
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32226-1205
Mailing Address - Country:US
Mailing Address - Phone:985-855-6457
Mailing Address - Fax:
Practice Address - Street 1:11401 OLD SAINT AUGUSTINE RD
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32258-1402
Practice Address - Country:US
Practice Address - Phone:904-260-1818
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-02-04
Last Update Date:2021-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL17781224Z00000X
MDA02713224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant