Provider Demographics
NPI:1841780996
Name:BRAUDRICK, DESTINY A (COTA/L, CLT)
Entity Type:Individual
Prefix:
First Name:DESTINY
Middle Name:A
Last Name:BRAUDRICK
Suffix:
Gender:F
Credentials:COTA/L, CLT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5026 BRIDGE RD
Mailing Address - Street 2:
Mailing Address - City:COCOA
Mailing Address - State:FL
Mailing Address - Zip Code:32927-9131
Mailing Address - Country:US
Mailing Address - Phone:321-720-9652
Mailing Address - Fax:
Practice Address - Street 1:7000 SPYGLASS CT STE 120
Practice Address - Street 2:
Practice Address - City:VIERA
Practice Address - State:FL
Practice Address - Zip Code:32940-7948
Practice Address - Country:US
Practice Address - Phone:321-241-6543
Practice Address - Fax:321-241-6513
Is Sole Proprietor?:Yes
Enumeration Date:2018-05-15
Last Update Date:2023-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOTA16265224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant