Provider Demographics
NPI:1841558293
Name:KING, ROBERTA (ROBERTA KING OTR/L)
Entity Type:Individual
Prefix:MRS
First Name:ROBERTA
Middle Name:
Last Name:KING
Suffix:
Gender:F
Credentials:ROBERTA KING OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:39 GLEN LAUREL DR
Mailing Address - Street 2:
Mailing Address - City:SAINT JOHNS
Mailing Address - State:FL
Mailing Address - Zip Code:32259-3288
Mailing Address - Country:US
Mailing Address - Phone:321-693-0625
Mailing Address - Fax:
Practice Address - Street 1:2245 PLANTATION CENTER DR
Practice Address - Street 2:SUITE 57
Practice Address - City:FLEMING ISLAND
Practice Address - State:FL
Practice Address - Zip Code:32003-3352
Practice Address - Country:US
Practice Address - Phone:190-437-4141
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-04-23
Last Update Date:2013-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOT6363225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist