Provider Demographics
NPI:1821748161
Name:GOTTLIEB, KENNETH ALLEN (COTA)
Entity Type:Individual
Prefix:
First Name:KENNETH
Middle Name:ALLEN
Last Name:GOTTLIEB
Suffix:
Gender:M
Credentials:COTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3001 GREYSTONE LOOP UNIT 106
Mailing Address - Street 2:
Mailing Address - City:KISSIMMEE
Mailing Address - State:FL
Mailing Address - Zip Code:34741-7825
Mailing Address - Country:US
Mailing Address - Phone:954-684-5658
Mailing Address - Fax:
Practice Address - Street 1:3001 GREYSTONE LOOP UNIT 106
Practice Address - Street 2:
Practice Address - City:KISSIMMEE
Practice Address - State:FL
Practice Address - Zip Code:34741-7825
Practice Address - Country:US
Practice Address - Phone:954-684-5658
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-03-28
Last Update Date:2022-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOTA3917224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy AssistantGroup - Single Specialty