Provider Demographics
NPI:1902361967
Name:SIEGEL, ANTOINETTE GRACE (OT)
Entity Type:Individual
Prefix:
First Name:ANTOINETTE
Middle Name:GRACE
Last Name:SIEGEL
Suffix:
Gender:F
Credentials:OT
Other - Prefix:
Other - First Name:ANTOINETTE
Other - Middle Name:GRACE
Other - Last Name:QUINONES
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:COTA
Mailing Address - Street 1:680 S 4TH ST
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40202-2407
Mailing Address - Country:US
Mailing Address - Phone:502-596-0749
Mailing Address - Fax:
Practice Address - Street 1:2575 HARRISON AVE
Practice Address - Street 2:
Practice Address - City:PANAMA CITY
Practice Address - State:FL
Practice Address - Zip Code:32405-4458
Practice Address - Country:US
Practice Address - Phone:850-296-2448
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-02-04
Last Update Date:2019-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOT19226225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist